
am 



PRACTICAL TREATISE 



DISEASES OF THE SKIN 



/ BY 

LOUIS 4? t)UHKING, M.D., 

PROFESSOR OF DISEASES OF THE SKIN IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA; 

DERMATOLOGIST TO THE PHILADELPHIA HOSPITAL; CONSULTING PHYSICIAN TO 

'I HE DISPENSARY FOR SKIN DISEASES, PHILADELPHIA; AUTHOR 

OF "ATLAS OF SKIN DISEASES," ETC. 






THIBD EDITION 
REVISED AND ENLARGED 






PHILADELPHIA 

J. B. LIPPINCOTT & CO. 

London: 16 Southampton Street, Covent Garden 
1882 



r 






V 



Copyright, 1882, by Louis A. Duhring, M.D. 



PREFACE 

TO THE 

FIEST EDITION. 



In preparing this volume it has been my aim to write a concise 
and practical treatise, one which, while making no pretensions to 
being exhaustive, should comprise sufficient to afford a clear in- 
sight into the elements of Dermatology and a knowledge of the 
important facts in connection with each disease treated of. The 
primary object being to render the subject simple and intelligible, 
and to free it from unnecessary encumbrances, it has been deemed 
best to avoid scrupulously all questions of theory, discussion of 
unsettled points, and the introduction of obsolete terms. Con- 
sideration of these and kindred topics, however interesting, would 
have carried the volume beyond the limits assigned to it. Nor, 
for the same reason, has any attempt been made to enter into the 
literature of Dermatology. For information of this character, I 
may refer the reader to the comprehensive and sterling work of 
Hebra and Kaposi, the translation of which is now in course 
of publication by the New Sydenham Society, of London. The 
subject-matter, indeed, has everywhere been rigorously condensed, 
in many instances, I am well aware, at the sacrifice of elegance 
of diction. 

The nomenclature employed is essentially that now in common 
use by the prominent writers and teachers of our own country 
and of Europe. 



4 PREFACE TO THE FIR-ST EDITION. 

The classification of Hebra, with certain changes and modifica- 
tions, has, after long and careful study, been adopted, from the 
conviction that when rightly comprehended it affords the most 
satisfactory and practically useful method of grouping cutaneous 
diseases with which we are familiar. 

Considerable attention has been bestowed upon the definitions 
of the various diseases. They have for the most part been made 
from a clinical stand-point, with a view to their being of practical 
value, and consist mainly of succinct descriptions of the character- 
isl i<- symptoms. In several instances, however, the subject appeared 
either so complex or so obscure that it was thought advisable not 
to attempt its definition. 

I can but incidentally refer to the fact that diseases of the skin 
manifest more or less variation in type as they occur in one or 
in another part of the world. Having had a few years ago 
favorable opportunities for observing a large number of cutaneous 
affections in the various countries of Europe, and since then of 
studying these diseases in the United States, I can state that in 
many instances they differ materially as they are seen on the two 
continents. Without entering into this interesting subject, it may 
be remarked that the diseases met with here resemble more closely 
those of Great Britain than those of either France or Germany. 
A recognition of this fact must, I think, go far in accounting for 
the discrepancies which exist in the descriptions of certain diseases 
as given by trustworthy observers. 

I desire to make special acknowledgment of the assistance 
derived from the writings of Hebra, Kaposi, Neumann, Wilson, 
Fox, and Anderson. 

In the sections devoted to treatment I have endeavored to 
mention the methods favorably regarded by dermatologists at 
large, but in particular to bring forward the remedies and modes 
of treatment which have proved of greatest benefit in my own 
experience. 



PREFACE TO THE FIRST EDITION. 5 

The illustrations of the structure of the normal skin and of 
the parasites are the work of my friend and co-worker Dr. Arthur 
Van Harlingen, to whom I cordially acknowledge my indebted- 
ness not only for the admirable original drawings, but also for 
many favors tendered during the preparation of this volume. 
My thanks are also due to Mr. J. McCreery, proof-reader, for 
acceptable suggestions made during the progress of the sheets 
through the press. 

The illustrations have been reproduced by the Photo-Engraving 
Company, of New York. 

LOUIS A. DUHRING. 

Philadelphia, 1416 Spruce St., 
December, 1876. 



PREFACE 

TO THE 

SECOND EDITION. 



The present edition has been thoroughly and carefully revised, 
many chapters having been entirely re-written. It is also con- 
siderably enlarged, to the extent of about one hundred pages, the 
type being slightly smaller than in the first edition. New matter 
has been liberally added, and will be found upon almost every page, 
together with critical remarks where such seemed to be called for. 
The effort has been faithfully made throughout the volume to 
present the subject in the light of the latest dermatological re- 
searches. The forward strides of Dermatology within the past 
few years have been remarkable. No specialty of medicine has 
grown so rapidly. Formerly a decade comprised comparatively 
few important discoveries, but now each year adds materially to 
our fund of knowledge. Frequently revised editions of works 
on diseases of the skin, therefore, are demanded. 

The chapter on the anatomy of the skin has been largely re- 
written, and two new illustrations have been added, one showing 
the general anatomy of the integument, the other the minute 
structure of the epidermis. Both were drawn by Dr. Van Har- 
lingen. Considerable matter pertaining to the physiology of the 
skin has also been incorporated with this chapter. 

The new articles are uridrosis, phosphorescent sweat, 

URTICARIA PIGMENTOSA, DERMATITIS CIRCUMSCRIPTA HERPETI- 

7 



8 PREFACE TO THE SECOND EDITION. 

FORMIS, IMPETIGO HERPETIFORMIS, PITYRIASIS MACULATA 
ET CIRCIN'ATA, DERMATITIS EXFOLIATIVA, DERMATITIS MEDI- 
CAMENTOSA, DERMATITIS GANGRENOSA, DERMATITIS PAPIL- 
LARIS CAPILLITH, FUNGOID NEOPLASM AT A, TUBERCULOSIS CUTIS, 
PODELCOMA, AINHUM, PERFORATING ULCER OF THE FOOT, and 
MYOMA CUTIS. 

Among the chapters which have been enlarged and to which 
important additions have been made, I may specially refer to 

DYSIDROSIS and POMPHOLYX, ILEMATIDROSIS, SCLERODERMA, 
MORPHCEA, ATROPHIA CUTIS, HYPERTROPHY OF THE HAIR, 
ATROPHY OF THE HAIR, SCROFULODERMA, SYPHILODERMA, and 
CARCINOMA. 

Thanking the Profession for the cordial reception extended to 
the previous edition, it is hoped that the volume now offered may 
prove even more worthy of support. 

January, 1881. 



PREFACE 

TO THE 

THIRD EDITION. 



This edition has been critically revised. The chapter on the 
anatomy and physiology of the skin has been re-written and 
elaborated, the recent studies in microscopic anatomy demanding 
this change. The work, as a whole, has been considerably 
enlarged. Numerous additions in the way of cases illustrating 
rare forms of disease, new and important observations, personal 
experience, and therapeutics, will be found upon almost every 
page. 

1411 Spkuce Street, May, 1882. 



CONTENTS. 



PART I. 

GENERAL CONSIDERATIONS. 

PAGE 

Anatomy and Physiology 17 

Symptomatology 53 

Etiology 70 

Pathology 78 

Diagnosis 86 

Treatment 94 

Prognosis 109 

Classification Ill 



PART II. 

SPECIAL DISEASES. 

CLASS I. 

ANOMALIES SECRETION IS— DISORDERS OF SECRETION. 

Seborrhcea 115 

Comedo . 128 

Milium 131 

Sebaceous Cyst 133 

Hyperidrosis . 134 

Anidrosis 139 

Bromidrosis . . . . . . . < . . . 140 

11 



12 CONTEXTS. 

PAGE 

Chromidrosia 142 

Uridrosis ' 143 

Phosphoridrosis 144 

Sudamen . . 145 



CLASS II. 
H YPER^EMI^E— HYPER JE MIAS. 

Erythema Simplex . 148 

Erythema Intertrigo 150 



CLASS III. 
EXSUDATIONES— INFLAMMATIONS. 

Erythema Multiforme 152 

Erythema Nodosum 156 

Urticaria • 158 

Urticaria Pigmentosa ......... 107 

Eczema 169 

Herpes 227 

Herpes Gestationis 230 

Herpes Zoster 231 

Herpes Iris 239 

Miliaria 242 

Dysidrosis, — Pompholyx 247 

Pemphigus 249 

Lichen Euber 2">7 

Prurigo 262 

Lichen Scrofulosus 267 

Acne . . 268 

Acne Rosacea 281 

Sycosis Non-Parasitica 288 

Impetigo 293 

Impetigo Herpetiformis 296 

Impetigo Contagiosa 297 

Ecthyma 300 

Psoriasis • 304 



CONTENTS. 13 



PA«E 



Pityriasis Kubra 323 

Pityriasis Rosea 326 

Dermatitis Exfoliativa 328 

Eurunculus 330 

Aleppo Boil . 333 

Anthrax 334 

Poisoned "Wounds 337 

Dissection Wounds -. . . 338 

Pustula Maligna . . .339 

Equinia 339 

Dermatitis r . 340 

Dermatitis Traumatica ......... 340 

Dermatitis Venenata 341 

Dermatitis Calorica 344 

Dermatitis Gangrenosa 344 

Dermatitis Medicamentosa 346 



CLASS IV. 
HEMORRHAGIC— HEMOREHAGES. 

Purpura 360 

Hsematidrosis 365 



GLASS "V. 
HYPERTROPHIC— HYPERTROPHIES. 

Lentigo 368 

Chloasma 370 

Argyria 375 

Nsevus Pigmentosus 376 

Molluscum Epitheliale ' . . 377 

Callositas . 382 

Clavus . . . . .383 

Cornu Cutaneum 385 

Verruca 387 

Papilloma . . . . 391 

Ichthyosis • 393 



1 4 CONTENTS. 

PAGE 

Keratosis Pilaris 399 

Scleroderma 400 

Morpboea 408 

Sclerema Neonatorum 414 

Elephantiasis 415 

Dermatolysis 420 

Hypertrophy of the Hair 422 

Hypertrophy of the Nail 427 



CLASS VI. 

ATROPHIA— ATROPHIES. 

Albinism 430 

Vitiligo 432 

Canities 435 

Atrophia Cutis 437 

Stria? et Maculae Atrophica . . . ( 442 

Senile Atrophy 443 

Alopecia 444 

Alopecia Areata 448 

Atrophy of the Hair 454 

Atrophy of the Nail 457 



CLASS VII. 

NEOPLASMATA— NEW GROWTHS. 

Keloid 458 

Molluscum Fibrosum 461 

Xanthoma 464 

Rhinoscleroma 468 

Lupus Erythematosus 470 

Lupus Vulgaris 475 

Scrofuloderma 485 

Tuberculosis of the Skin 489 

Podelcoma 490 

Ainhum 490 

Perforating Ulcer of the Foot 491 



CONTENTS. 15 

PAGE 

Lepra 492 

Frambcesia 503 

Pellagra 505 

Syphiloderma 506 

Carcinoma 547 

Epithelioma 548 

Sarcoma ............. 559 

Nsevus Vasculosus 563 

Telangiectasis 568 

Rosacea 568 

Lymphangioma ............ 569 

Neuroma 571 

Myoma Cutis 573 



CLASS VIII. 
NEUROSES. 

Hypersesthesia 576 

Dermatalgia 577 

Pruritus 579 

Pruritus Hiemalis 588 

Anaesthesia 591 



CLASS IX. 
PARASITE— PARASITES. 

Tinea Favosa 593 

Tinea Circinata 602 

Tinea Imbricata 611 

Tinea Tonsurans 612 

Tinea Kerion ........... 622 

Tinea Sycosis 623 

Tinea Versicolor 629 

Scabies 637 

Leptus 648 

Pulex Penetrans . 649 

Filaria Medinensis 649 



16 CONTENTS. 

PAOl 

Cysticercus Cellulosie 650 

(Estrus 651 

Demodex Follieulorum 651 

Pediculosis 653 

Cimex Lectularius 663 

Pulex Irritana 664 

Culex 664 

Ixodes - 66r, 



DISEASES OF THE SKIN. 



PAET I. 

GENERAL CONSIDERATIONS. 



ANATOMY AND PHYSIOLOGY. 

The skin, or integumentum commune, is a covering which 
invests the body completely. It is a flexible membrane, and 
possesses both elasticity and extensibility. It also possesses con- 
siderable power of resistance. From without it resists innumerable 
external agencies, thus serving as a protecting organ. Upon its 
surface are numerous lines or markings, of various size and form, 
which are particularly well defined about the face, hands, and 
feet. Larger and coarser furrows occur about the joints, and 
likewise on the face and neck. 

Numerous minute depressions, or pores, also exist upon the sur- 
face, the orifices of glandular ducts and of hair-follicles. Hairs, 
both coarse and fine, are found upon almost all regions of the 
body, but are more abundantly present in some parts than in 
others. The largest occur upon the so-called hairy regions ; the 
finest upon various other localities, as, for example, the back. 
Upon certain parts of the integument they are wholly absent. 
Thus, they are not met with upon the palms of the hands, the 
soles of the feet, or the dorsal surfaces of the last phalanges of 
the fingers and toes. 

To the touch the general surface of the skin in protected parts 
has a soft, smooth, more or less unctuous feel ; in certain locali- 

2 17 



18 ANATOMY AND PHYSIOLOGY. 

ties, however, especially in exposed parts, it is uneven, rough, or 
even harsh. In color it varies greatly, being encountered pos- 
sessing all shades from whitish-pink to yellow, brown, and black, 
according to the race. In the individual, moreover, different 
shades are found in different regions. In the white race, pig- 
mentation is most marked in the areola of the nipples and about 
the genitalia. In thickness it likewise varies, depending upon 
the locality ; it is thickest on the back, buttocks, palms, and soles, 
and thinnest on the eyelids and prepuce. 

The skin is to be considered as an organ of sensation, especially 
of touch, by means of which we obtain knowledge of the objects 
with which we come in contact. It is highly sensitive, and by it 
we are enabled to recognize, and moreover localize, various ex- 
ternal impressions, as pressure, injuries, pain, and tickling; also 
to distinguish between heat and cold, hardness and softness, and 
other opposite qualities and degrees of difference. Tactile sensi- 
bility is found to vary in different parts of the body, being most 
acute upon the ends of the fingers. 

The skin is to be viewed also as an organ of absorption. It 
possesses decided absorptive properties. Gases are readily taken 
up by dry or moist skin under favorable circumstances. In two 
series of experiments, conducted in 1819 and 1825 by Lebkiichner, 
the bodies of animals were placed in sulphuretted hydrogen 
leaving the heads exposed, in each instance causing the death of 
the animal.* More recently Roehrigf has performed similar 
experiments upon rabbits with the same result; also, with car- 
bonic acid gas, the animals in both cases dying of symptoms of 
poisoning by these gases. It is known that sulphur baths act 
favorably in lead poisoning by the absorption of their gaseous 
constituents. 

Certain fluid substances, as, for example, chloroform, tincture 
of iodine, tar, and carbolic acid, are also absorbed. Water and 
watery solutions are also taken up into the system through the 
skin. In favor of this statement is the well-known fact that baths 
containing corrosive sublimate act beneficially in syphilis, the 
mercury being without question absorbed. Oils and ointments 

* Quoted by Hillairet, Traitc theorique et pratique des maladies de la 
peau, Paris, 1881, premier fascicule, p. 36. 
f Archiv fur Heilkunde, xiii., pp. 341-348. 



ANATOMY AND PHYSIOLOGY. 19 

of some kinds, as linseed and cod-liver oils, and belladonna and 
mercurial ointments, are also readily absorbed by the skin, and 
form a frequent means of acting upon systemic diseases. As an 
instance, the inunction of mercurial ointment in syphilis may be 
cited. Whether substances absorbed pass in through the general 
surface or only through the glandular and follicular orifices has 
not as yet been conclusively decided, but I incline strongly to the 
view that it occurs exclusively by the latter way.* Owing to the 
imperviousness of the corneous layer of the epidermis, the skin 
serves to retain moisture in the tissues beneath it, and thus pre- 
vents the too rapid evaporation of fluid from the surface. 

The skin is to be regarded as a secreting organ. It secretes 
both sebaceous matter and sweat, which serve to give it supple- 
ness and softness. Certain regions give out these secretions in 
greater abundance than others ; the scalp, for instance, is well 
provided with sebaceous glands, and the axilla? with sweat glands. 
The function of perspiration is an important one, and plays a 
conspicuous part in the economy. When it occurs in an imper- 
ceptible manner, evaporating as rapidly as it is formed, it is termed 
insensible; when in excess, in the form of drops, sensible. The 
amount of this secretion normally poured out in the course of 
twenty-four hours, in the case of an adult, has been estimated at 
about two pounds. Roehrigf places it at one pound nine ounces 
troy. It varies with individuals, and depends, moreover, upon 
the external temperature and other circumstances. Under cer- 
tain conditions, however, the amount mentioned may be greatly 
increased, so that in a hot air bath, for instance, as much as a 
pound and a half may be secreted within half an hour. Certain 
gases, as carbonic acid, possibly nitrogen, and other substances, 
are eliminated from the body, probably through the sudoriparous 
glands. 

According to Seguing a comparison between the respiration by 



* See Auspitz, Ueber die Eesorption ungeloster Stoffe bei Saugethieren. 
Wiener Med. Jahrb., 1871. Abstract by me, Phila. Med. Times, vol. i. 
No. 24. Neumann, Ueber die Aufnahme des Quecksilbers durch die unver- 
letzte Haut. "Wien. Med. Wochenschrift, 1871. Also Roehrig, 1. c. 

f Die Physiologie der Haut, Berlin, 1876. 

+ Mem. de l'Acad. de Paris, 1790, et Annales de Chimie, t. xc. (Quoted 
by Roehrig.) 



20 ANATOMY AND PHYSIOLOGY. 

the skin and that by the lunga shows that the same products are 
given off by each organ. The amounts eliminated by perspira- 
tion and by respiration stand in a tolerably constant relation one 
to the other. The quantity of water thrown off by cutaneous 
transpiration, according to the same authority, bears the propor- 
tion to the lung transpiration of two to one. Valentin* estimates 
the amount as nine to five. As Roehrig states, however, the 
greater part of the excretion by the skin is in the form of water. 
The amount of carbonic acid given off during a stated time, ac- 
cording to Roehrig, varies in proportion to that given off from the 
lungs from 1 : 25 to 1 : 92. The reason the excretion by weight 
from the lungs appears to be so much less than that by the skin is 
found in the fact that the lungs are constantly absorbing oxygen. 
The actual transpiration through the lungs is more than double 
that indicated by the loss of weight. The skin absorbs only a 
trifling amount of oxygen, according to Gerlachf only 1 : 137 of 
the amount of carbonic acid thrown off. It will be seen, there- 
fore, that the skin plays a comparatively insignificant part in the 
interchange of gaseous matter between the body and the surround- 
ing atmosphere. This is readily explained by the density of the 
epidermis compared with the delicate epithelial lining of the 
lungs. Excretion by the skin is increased by imperfect or labored 
respiration, by food, and also by higher temperature. 

The skin, viewed anatomically, is a complex organization. It 
consists of parts, some of which are essential, being everywhere 
present, while others exist only in certain regions. Of the former 
there are the epidermis, the corium, and the subcutaneous connec- 
tive tissue ; of the latter, which are termed appendages, there are 
sebaceous glands, sweat glands, hairs, and nails. In addition to 
the parts already mentioned, the skin contains bloodvessels, lym- 
phatics, and nerves. In order to obtain a thorough comprehen- 
sion of the subject it will be necessary to consider these various 
structures separately. 

EPIDERMIS. 

The epidermis, cuticula, or cuticle, is a membrane composed 
entirely of cells, which covers the corium in all its parts, adapting 

* Kepert. f. Anat. u. Phys., Bd. viii. (Quoted by Koehrig.) 
f Quoted by Koebrig, loe. cit., p. 36. 



ANATOMY AND PHYSIOLOGY. 



21 



itself closely to the various elevations and depressions of this 
structure. It is made up of the following strata : (a) Stratum 
corneum. (6) Stratum lucidum. (c) Stratum granulosum. (d) 
Stratum mucosum. Practically, however, it consists of but two 
layers, the corneous and the mucous, which may be separated 
from each other by reagents or by vesicants. 





Fig. I. — Diagrammatic Vertical Section op Normal Skin. A, Stratum corneum of the epi- 
dermis. B, Stratum lucidum. C, Stratum granulosum. D, Stratum mucosum. E, Corjum, with 
papillae. F, Tactile corpuscle. G, Papilla with vascular loop. H, Sebaceous gland. I, Erector- 
of-the-hair muscle. J, Hair. K, Pacinian corpuscle. L, Sweat gland. M, Subcutaneous connec- 
tive tissue. 



Stratum corneum — Corneous layer — Horny layer. — This is the 
external or superficial layer, and constitutes the uppermost part 
of the epidermis. It serves to protect the true skin mechanically. 
It follows the elevations and depressions of the tissues beneath, 
which gives it an undulating surface, especially marked where the 
papillse are well developed. It consists of variously sized and 



22 ANATOMY AND PHYSIOLOGY. 

shaped, transparent cells, closely packed in the form of strata. 
The cells vary according to the part of the stratum in which they 
are found. In the vicinity of the stratum lucidum they are more 
distinctly defined, succulent, and full than in the upper strata. 
They are polygonal or fusiform, frequently show a shrunken nu- 
cleus, and stain only faintly. Towards the surface they become 
flatter, drier, and more shrivelled in appearance, and stain even less 
markedly. No nuclei are met with here. Upon the surface they 
exist as dried, more or less wrinkled or crumpled cells, known as 
epidermic scales. They measure about -faf" (.0252 mm.). 

Detached from the tissues beneath and viewed as a whole, the 
horny layer is seen to be a whitish, opaque membrane, varying in 
thickness and density according to the locality from which it has 
been removed. It is thickest on the palms of the hands and on 
the soles of the feet. Its thickness does not depend on the de- 
velopment of the stratum mucosum. In some localities where 
this layer is thick the horny layer is thin. 

Stratum lucidum. — The stratum lucidum, known also as the 
stratum of Oehl,* is a thin, bright, homogeneous or indistinctly 
striated layer composed of flattened cells containing a staff-shaped 
or flattened nucleus. According to Robinson,f it is made up of 
at least three layers of cells. The cells are formed from those of 
the granular layer. According to Unna,| in their movement to 
the free surface the latter become less granular and the inter- 
granular substance grows more transparent and shining. The 
change begins around the nucleus, whence it gradually extends 
to the periphery of the cell. The nucleus, also, usually becomes 
invisible. § The stratum lucidum belongs to the corneous layer 
rather than to the granular layer and rete. 

Stratum granulosum — Granular layer. — The granular layer (of 
Langerhans), called also the layer of the granular cells, is a narrow 
stratum of flattened, granular cells, looking spindle-shaped in ver- 
tical section, with their long diameter parallel to the free surface 

* Indagini di anatomia microscopic:* per servire alio studio dell' epidermide 
e della cute palmare della mano. Annali Universali di Medicina. Milano, 
1857. 

f Article on the Anatomy of the Skin, hy A. E. Robinson, M.D., in A 
Manual of Histology, hy Thomas E. Satterthwaite, M.D., New York, 1881. 

% Archiv fur Mile. Anat., Bd. xii., 187G. 

\ Robinson, loc. cit. 



ANATOMY AND PHYSIOLOGY. 23 

of the epidermis. They have a distinct clear nucleus, from the 
poles of which, according to Klein,* extend rod-like or disk- 
shaped granules, gradually diminishing in size from the nucleus 
outwards. The cells in this layer are no longer connected with 
one another by prickles or bands, as in the stratum mucosum, to 
be referred to. Langerhansf and UnnaJ make this layer composed 
of two rows of cells. Klein states that it varies in thickness in 
different localities, like the epidermis as a whole. In some places 
where the epidermis is very thick this layer is also well developed, 
consisting of three, four, or more layers of cells. In other places 
where the epidermis is very thin it is only rudimentary. The 
structure of the cells of this stratum is best seen in specimens 
stained with hsematoxylon. The contrast between the fusiform 
cells of this layer and the prickle-cells of the rete below is marked, 
although the line of separation cannot be regarded as a sharp one. 
The upper border, however, against the stratum lucidurn, is clearly 
denned. 

Stratum mucosum — Mucous layer — Rete mucosum — Rete Mal- 
pighii — Stratum Malpighii. — This is situated beneath the granu- 
lar layer. It is in direct contact with the corium, resting on the 
papillary layer. It is sunk in between the papillae, as the inter- 
papillary projections or processes. Where these processes dip 
down the layer is of course much thicker than over the summits 
of the papilla?. The thickness of the layer as a whole varies 
somewhat in individuals, but it is subject to less variation in this 
respect than any other layer of the skin. The stratum mucosum 
is composed of nucleated cells, which differ somewhat in size and 
in shape in the several layers. Three variations may be noted. 
In the deepest layer, seated upon the corium, they are columnar 
in shape, with oval nuclei. The lower borders of the cells are 
elongated or pointed, and give to the border a notched or toothed 
appearance. The layer is fixed to the surface of the corium by 
the same albuminous cement-substance as that which is found 
between the cells. According to the observations of Robinson,§ 
the cells of this layer are not united to one another by bands, as 
in the other layers. The next several layers of cells above are 

* Atlas of Histology, Phila., 1879. 

f Archiv. fur Mik. Anat., Bd. ix., 1873. 

% Loc. cit. | Loc. cit. 



24 ANATOMY AND PHYSIOLOGY. 

well defined, and are polyhedral in -hape, each with a spherical 

nucleus. These cells contai ore or less pigment, the amount 

varying with the race and individual, and with the locality. Lastly, 
as ili<' granular layer is approached, the cells become larger, Hatter, 
and more granular in appearance. According to Robinson, "the 
granular structure, which in the lowest layer is most marked around 
the nucleus, gradually extends toward- the margin of the cells as 
the surface is approached, so that finally a clear area is seen around 
the nucleus, whilst the remainder of the cell-body is markedly 
granular. At the same time' the cell-body becomes firmer and the 
nucleus smaller." 

The cells of the stratum Malpighii are closely united, and it is 
difficult to isolate them. This may he best accomplished by long 
immersion in iodized serum. In a state of isolation they resemble 
in outline a chestnut burr. Under inflammatory conditions the 
intercellular substance increases to a considerable extent, and hence 
the cells become more separated from one another, and the prickles, 
on account of their greater length, are better seen.* Wandering 
lymphoid cells are frequently encountered in the stratum muco- 
sum, especially in the lower part, more particularly in certain 
pathological states. They are observed in the form of elongated, 
spindle-shaped bodies lying between the cells of the mucous 
layer. 

The cells of the stratum niucosum are all rich in protoplasm. 
Following the observations of Robinson, all the cells, except those 
of the first row, are united to each other by filaments, the so- 
called prickles, or thorns, of Max Schultze, which have also been 
investigated by Martyn,f Bizzozero,| and Heitzmann.§ "These 
uniting filaments, or bands, vary much as regards their size and 
length in different parts of the body. They arc most distinct 
wherever the Malpighian layer is well developed, but are thicker 
and longer in the lower rows of cells than in the upper. At the 
stratum luciduiu they cease to exist. Between neighboring cor- 
puscles the length of these bands is in direct proportion to the 
distance between the borders of the cell-bodies. Hence, where 

* Klein, Inc. cit. 

f Brit. Med. Jour., June 26, 1875. 

X Quoted by Heitzmann, loc. cit. 

\ Sitzungs-Ber. der Kais. Akad. d. Wissensch. Wien, ls7". 



ANATOMY AND PHYSIOLOGY. 25 

three or four cells meet at one place, the minute filaments are 
much longer than those uniting the bodies of closely adjoining 
cells. Examining these prickle-cells with the microscope, alternate 
dark and light bands are seen between the cell-borders. With a 
low power, these light bands appear to consist of spaces between 



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' i !> - r> 



.J 






Fig. II. — Epidermis and Papillary Layer. A, Stratum corneum of the epidermis. 
luciJum. C, Stratum grauulosum. D, Stratum mucosum. E, Papillary layer of the i 



the connecting filaments, the dark lines being the connecting 
filaments, but with a high power the latter can be recognized as 
spaces between the former. The light bands can be traced from 
the surface of one cell to the surface of another, whilst the dark 
lines are the spaces between these bands. These connecting cords 
sometimes divide and anastomose with one another, forming a sort 
of net-work between the cells. In this case the dark spaces do 
not always extend from one cell-body to another, since they may 
correspond to the space between anastomosing filaments. These 
bands are, therefore, not the prickles of adjoining cells, which 
interlock with one another, but are true connecting filaments be- 
tween cells of a common origin, and which have not yet become 
separated from one another. The connecting bands, or fibres, 



26 ANATOMY AND PHYSIOLOGY. 

gradually diminish in length and in thickness from below up- 
wards, and finally cease to exist when the granular layer is reached. 
The spines between the hands are filled with an intercellular 
albuminous substance, and may be regarded as minute channels 
for the conveyance of nutriment to the cells of the epidermis."* 

The epidermis varies greatly in thickness ; it is thinnest about 
the lips, ;ind thickest upon the palms and soles. It is thinner on 
the flexor than <>n the extensor surfaces of the limbs. It meas- 
ures from T y " (.0282 mm.) to 1 '" (2.1 1 6 mm.) or more. Its sur- 
face presents a series of furrows or linear markings. Two kinds 
may be distinguished : a larger and deeper variety, occurring in 
connection with the joints and flexures of the body, and a smaller, 
more superficial variety, traversing the whole surface in various 
directions, and dependent upon the arrangement of the papillae 
of the corium. The latter are to be seen upon all regions of the 
skin, in the form of a mosaic pattern, intersecting and forming 
small, polygonal spaces. Both perform a service in the movements 
of the body and of the skin itself. They have been made the 
subject of careful study, as regards their direction and special 
localization, by C. Langer,f Swercbesky,J and more recently by 
Oscar Simon.§ 

CORIUM. 

The corium, called also derma, cutis, and cutis vera, or true 
skin, is the most important part of the integument. It is a firm 
structure, made up mainly of white fibrous and elastic tissue. It 
contains bloodvessels, nerves, lymphatics, smooth muscles, hairs, 
sebaceous glands, sweat-ducts, and fat cells, which are situated in 
the interfascicular spaces. It is divided into two portions, an upper 
and a lower, termed respectively the papillary and the reticular 
layer. These layers are not divided by any line, but pass gradu- 
ally into each other. The superficial portion of the corium is 
raised into prominences, to be referred to, while the deep por- 
tion passes without line of demarcation into the subcutaneous 
connective tissue. 



* Robinson, loc. fit. 

•J- Sitzungs-Bcrichte der Kais. Akad. d. Wiss. "Wien, 1861, Bd. xliv., xlv. 
% Amer. Jour, of Syph. and Derm., July, 1871. 

\ Die Localisation der Hautkrankheiten, histologiseh und klinisch bear- 
beitot. Mit 5 Tafeln. Berlin, 1873. 



ANATOMY AND PHYSIOLOGY. 27 

The boundary between the stratum mucosum and the coriura 
is marked by a pale, thin, membranous structure with oval nuclei, 
the so-called basement-membrane. It is conspicuous in stained 
preparations. According to Klein's observations, it is made up 
of the basis of the individual epithelial cells which has undergone 
a chemical and morphological change. It is to be regarded as a 
product of the deepest layers of the epithelium. 

As stated, the corium is composed largely of fibrous connective 
tissue and of elastic tissue. The former is present in the form of 
small and large bundles, or trabecular, which cross one another 
in various directions, producing a more or less close net-work. 
This is dense in the upper and looser in the lower portion of the 
corium. The connective-tissue corpuscles are transparent cells, 
with oval nuclei, possessing filamentous processes. Wandering 
cells also are met with, especially near bloodvessels. Elastic fibres 
are found in all parts of the corium. They occur as fine and coarse 
fibres, connected by lateral branches into a net-work, their size 
and number, according to Klein, varying in different localities 
and in different individuals. They run parallel with the trabecular. 
In the lower strata they form a large net-work. According to 
Ravogli,* the number of elastic fibres increases with advancing 
years, and with this increase there is a corresponding decrease of 
the white fibrous connective-tissue cells. 

Papillary layer — Pars papillaris. — In this layer, which derives 
its name from the peculiar formation of its upper surface, the 
bundles of connective tissue are fine and beneath the papilla? run 
horizontally, or parallel with the surface of the integument. The 
net-work is dense, and the interfascicular surfaces are consequently 
small and numerous. The tissue here is intricately bound together 
or felted. 

The papillae consist of small, firm, finger-like or nipple-like 
prolongations or prominences arising from the upper surface of the 
corium. They vary both in size and in shape, and also in num- 
ber, according to the region in which they exist. They are con- 
ical or club-shaped in form, and are either single or are associated 
together by a common base, when they receive the name of com- 
pound papillae. The largest and most perfectly developed papillae 

* Quoted by Bobinson, loc. cit. 



28 ANATOMY AND PHYSIOLOGY. 

are found on the palm of the hand, upon the inner surfaces of the 
fingers and toes, especially on the terminal phalanges, and on the 

sole of the foot, where they have the form of more or less elon- 
gated nipple-shaped bodies, with circular bases. They are also 
large and well defined on the scalp. Upon the face they are 
shorter and broader. Where the skin is thin, as on the flexor 
surfaces of the arms and thighs, they arc less developed, and in 
some regions exisi merely as slighl elevations. In size they vary, 
measuring upon an average about fa'" (.0705 mm.). 

Their arrangement likewise varies. They are, however, for the 
most part arranged in the form of either straight, curved, or semi- 
circular lines. Upon the tips of the fingers they are placed side 
by side in stria?, two or more rows of them being included within 
one of the external lines of the epidermis visible to the naked 
eye. A- ( ). Simon* has shown, their systemic linear arrange- 
ment depends upon the linear direction of the connective-tissue 
bundles. They are present in great number on the palm, sole, 
and matrix of the nail. Meissnerf counted upon the end of 
the finger four hundred to one square line (2.116 mm.) of sur- 
face. According to Sappey,$ there are about. 60,000 papilla? to 
the square inch, which for the whole surface of the body would 
give 150,000,000. They may be divided into two kinds, accord- 
ing to their internal structure, vascular and nervous, or sensory. 
The former are well supplied with bloodvessels, while the latter 
are made up in great part of a peculiar tissue containing nerve 
elements and possess but a limited amount of vascularitv. 

According to Auspitz,§ the formation of the papillary layer in 
the embryo is subsequent to that of the epidermis. The latter 
about the end of the third month begins to extend downwards, 
pushing itself into the tissue of the corium in digital processes 
like fingers thrust into soft Max, forming at the same time the 
glands and hair-follicles. 

Reticular layer— Pars reticularis. — The papillary layer merges 
into the reticular layer without distinct line of demarcation, the 

* Loo. (it. 

f Beitrage zu-r Anat. und Phys. der Haut. Leipzig, 1853. 
% Traits d'Anatomie, t. iii. Paris, 1S72. 

\ Ueberdas Verhaltnias der Oberhaut zur Papillarscbicbt. Archivf. Derm, 
u. Syph., 1870, p. 31. 



ANATOMY AND PHYSIOLOGY. 29 

difference between these strata consisting in the arrangement of the 
connective-tissue fibres. The reticular portion is looser in texture 
than the papillary layer, and is made up of fasciculi of connective 
tissue, which decussate obliquely and give it a plexiform appear- 
ance. The bundles cross one another singly or in groups, are 
narrow or broad, and are more or less undulating in course. As 
these bands of tissue ascend towards the surface, they are observed 
to divide and to continue dividing into smaller and finer bundles 
until they reach the papillary structure, where only a few of the 
fibres are seen to interlace. The interfascicular spaces are seen to 
best advantage in this layer. 

The thickness of the corium varies in different regions. Kolli- 
ker* estimates it to average from \'" (.2645 mm.) to 1 \'" (3.174 
mm.) ; in most localities it will be found to measure about \'" 
(.5290 mm.). It is thickest upon the soles, palms, buttocks, and 
back, and thinnest upon the eyelids, prepuce, and labia majora. 
It is bounded above by the mucous layer of the epidermis, and 
below by the subcutaneous connective tissue, into which it in- 
sensibly passes. 

SUBCUTANEOUS CONNECTIVE TISSUE. 

This portion of the integument is made up of variously sized, 
for the most part cylindrical, bundles or fasciculi, of connective 
tissue, which cross one another obliquely and form a net-work. 
The meshes, though variable in size, are generally large, and the 
interfascicular spaces consequently well defined. Compared with 
the corium it is a loose structure, and contains usually an abun- 
dance of fat. This is found to exist in large quantity about the 
mammary glands, palms, and soles. In some regions, however, 
the subcutaneous connective tissue is without fat, as about the 
ears and eyelids. Where the fat lobules are found in number, 
the layer receives the name of adipose tissue, or panniculus adi- 
posus. J. Collins Warrenf describes columnar prolongations of 
this tissue, or fat columns, passing in a nearly vertical direction 
from the adipose tissue to the bases of the hair-follicles, especially 
to those of the fine hairs. The condition is found where the cutis 



* Manual of Human Microscopic Anatomy. London, 1860, p. 76. 
f Boston Med. and Surg. Jour., April 19, 1877. 



30 ANATOMY AM) PHYSIOLOGY. 

is exceptionally thick, as <>n the back and shoulders. The axes 
of these columns are parallel to those of the arrector pili muscles. 
Besides fai the columns contain a Budoriparous gland, and serve 
as channels i'<»r bloodvessels and lymphatics. From the points 
whence they ascend from the panniculus a cone-shaped mass of 
connective tissue is given off from the lower border of the cutis, 
which penetrates the adipose tissue for some distance, giving it a 
lobulated appearance. These bundles of fibres have been alluded 
to by French writers as cdnes fibreux, and are the attachments of 
the skin to the parts below. Dr. Warren is of the opinion that 
these "columnse adiposse" afford flexibility to the dense integu- 
ment and facilitate the action of the erector muscles, and that they 
probably play a part also in the nutrition of the upper layers 
of the skin and its glands; also that in disease they serve as an 
outlet for morbid elements pressing up from beneath, examples of 
which have been seen in round-celled sarcoma of the subcutaneous 
connective tissue, in nsevi, and in carbuncle, whose peculiar appear- 
ance in the last named disease is accounted for by these structures. 
The collections or lobules of fat, or fat glands, as they may be 
termed, consist of rounded, oval, or polyhedral fat cells closely 
packed together and enclosed in a net-work. The form depends 
upon the amount and the direction of pressure to which they are 
subjected. According to Ravogli,* the connective-tissue cells of 
this layer and also of the corium consist of branched cells which 
surround the white fibrous bundles and send in processes between 
the fibres. The elastic-tissue fibres are developed from the pro- 
cesses of the branched cells. Lymphoid cells are also met with 
in this tissue, which, according to Robinson, exist in greatest num- 
ber near the bloodvessels and glands. According to Biesiadecki,f 
the fat cells possess a very thin membrane, containing a minute 
drop of oil, which keeps the membrane so tightly stretched that 
it is scarcely discernible during life. The fat may, however, be 
extracted with ether, when the thin membrane will be seen, with 
a round nucleus. Each fat lobule is supplied with a fine plexus 
of bloodvessels, and each cell is further surrounded by a delicate 
capillary vessel. Large bloodvessels pass through the subcu- 

* Quoted by Robinson, loc. cit. 

f Strieker's Human and Comparative Histology. London, 1872, vol. ii. p. 
219. 



ANATOMY AND PHYSIOLOGY. 31 

taneous connective tissue, giving off branches to the corium and 
the structures contained within it. Pacinian corpuscles, nerves, 
lymphatic vessels, sweat glands, and the lower part of the hair- 
follicles of deep-seated hairs are also found here. Above it 
blends intimately with the corium, while its deeper layers are 
connected with the superficial fascia of muscles. The presence 
or absence of fat in this layer of the skin determines to some 
extent the external form of the body. 

BLOODVESSELS. 

The bloodvessels of the skin and subcutaneous connective tissue 
have been carefully studied by Tomsa.* Both the corium and 
subcutaneous tissue are highly vascular, having numerous blood- 
vessels throughout their structure in the form of trunks and 
capillaries. Two parallel horizontal plexuses exist, one superfi- 
cial, in the papillary layer of the corium, the other deep, in the 
subcutaneous tissue. The main vessels of the corium ascend 
from the subcutaneous tissue, and give off branches laterally in all 
directions, supplying the glands and hair-follicles as well as the 
corium itself. Towards the papillary layer a delicate and highly- 
organized plexus of capillaries exists, affording an abundant supply 
to this region. The papillae receive capillary loops, which run 
through their centre, or at their sides, parallel to their long axes. 
According to Thin,f the papilla? containing developed nervous 
structure are supplied with very fine capillary loops. Robinson 
states that these papilla? frequently have no bloodvessels. 

LYMPHATICS. 

The lymphatics of the skin have been studied by Sappey,| 
Teichmann,§ Biesiadecki,|| Neumann,^" and more recently by 



* Archiv fur Dermatologie und Syphilis, Heft 1, 1873. 

f Jour, of Anat. and Phys., vol. viii., 1874, p. 37. 

I Traite d'Anatomie, t. ii. Paris, 1872. 

\ Das Saugadersystem vom anat. Standp. bearb. Leipzig, 1861. 

|| Untersuch. aus d. Path.-Anat. Inst, in Krakau. "Wien, 1872. See also 
Strieker's Human and Comparative Histology, vol. ii. p. 225. 

\ Zur Kenntniss der Lymphgefasse der Haut des Menschen und der 
Saugethiere. Wien, 1873. Abstract by me, Phila. Med. Times, vol. iii. No. 



32 



ANATOMY AND PHYSIOLOGY. 



Klein,* whose careful observations I shall quote.f The skin is 
abundantly supplied with lymphatic vessels. Neumann demon- 
strate! them in the papilla?, in the corium, in the subcutaneous 
and adipose tissues, and in connection with the hair-follicles and 
sebaceous and Bweat -lands. According to Klein, they may be 
divided into the lymphatics of the connective-tissue matrix; the 
adipose tissue ; the sweat glands ; the hair-follicle; and the seba- 
ceous glands. All the layers of the corium and subcutaneous 
tissue contain plexuses of lymphatic vessels, whose wall is a single 
layer of elongated spindle-shaped or flattened endothelial plates. 
Many of them are possessed of valves and corresponding con- 
strictions. The vessels of the superficial layer of the corium are, 
on the whole, larger than those of the next layers of the corium, 
while those of the subcutaneous tissue are the largest. The di- 
rection of these plexuses is for the most part horizontal, but 
vessels also pass obliquely through the corium. The plexuses in 
the several strata of the corium are denser than in the subcutane- 
ous tissue. From the plexus of the superficial layer of the corium 
saccular or tubular vessels ascend into the papillae. These either 
terminate with a csecal extremity or form a compound loop. In the 
various strata of the corium, including the papillae, there are fine 
vessels which are connected with the plexus of the corresponding 
layer or terminate freely either with a pointed extremity, running 
out into a fine canal, or with a csecal extremity. These vessels have 
no valves and correspond to true lymph capillaries. Both the 
arterial and the venous branches are either accompanied on one 
or on both sides by a lymphatic vessel, or are crossed obliquely 
by such a vessel. 

Concerning the relation of the lymphatic vessels to the inter- 
fascicular spaces and to the stratum mucosum of the epidermis, 
Klein is of the opinion that the lymphatic capillaries stand in an 
open communication, by true stomata, with these spaces, which he 
regards as the lymph rootlets. In the same manner the lymphatic 
rootlets or interfascicular spaces of the papilla? and the superficial 
parts of the corium 'are connected intimately on the one hand 



* Loc. cit. 

f For further information on the lymphatic system the reader is referred 
to the article of Dr. W. E. Birdsall, in Satterth wake's Histology, New York, 
1881. 



ANATOMY AND PHYSIOLOGY. 33 

with the interstitial substance of the stratum mucosum, and on 
the other with the lymphatic vessels. 

The adipose tissue is richly supplied with lymphatics, in the 
form of plexuses in the interlobular connective-tissue septa and 
in the intralobular lymphatic vessels. The interlobular vessels 
are very numerous, and take up everywhere fine clefts and sinuses 
which are traceable between fat cells. Between the coils of the 
tubes of the sweat glands lymph-clefts are also found ; and the 
alveoli of the sebaceous glands are surrounded by lymphatic 
spaces and sinuses, connected both with lymphatic vessels and 
with the interfascicular lymph-spaces of the surrounding connec- 
tive tissue. The hair-follicle likewise contains lymph channels, 
which are in communication with the surrounding lymphatics. 

NERVES. 

Both medullated and non-medu Hated nerve fibres exist in the 
skin ; the former terminate, as a rule, in peculiar bodies, called 
the corpuscles of Pacini or of Vater ; while the latter, the non- 
medullated fibres, end as a delicate plexus in the upper layers of 
the corium and in the rete mucosum. In the corium some of the 
medullated nerves pass into non-medullated nerve fibres. Nerves 
accompany the more important bloodvessels. The larger nerve 
trunks come up from the subcutaneous connective tissue and divide 
at the corium, taking various directions according to the region 
they are to supply. 

Medullated Nerves. — Under this head the tactile and Pacinian 
corpuscles are to be considered. 

TACTILE CORPUSCLES. 

These bodies are also called touch corpuscles, corpuscles of 
Meissner, and corpuscles of Wagner. They are elongate, ovalish, 
or roundish in form, and are found situated in the papillse of the 
corium, or, occasionally, in the subpapillary stratum, attached to 
medullated nerve fibres. As a rule, they occupy the greater por- 
tion of the papillae, and are visible in prepared sections of skin 
as large, well-defined, firm-looking bodies having a transversely 
striated or corded exterior. According to Thin, two or more cor- 
puscles may occupy- one papilla, but, as Robinson states, frequently 
an appearance as if two corpuscles were present is produced by a 



34 ANATOMY AND PHYSIOLOGY. 

single corpuscle having the shape of a figure 8. The intimate 
structure of these bodies is still involved in uncertainty. Accord- 
ing to the studies of Langerhans* and Thin,f they consist of a 
mass of nucleated cells, probably connective tissue, held closely 
together by delicate connective-tissue fibres. A medullated nerve 
fibre penet ran- each corpuscle, usually at its base, and winds itself 
with a variable course both around and throughout the interior of 
tli«' structure. The mode of termination has not yet been defi- 
nitely ascertained. Robinson inclines to the view that the nerve 
does not terminate within the corpuscle, but passes on into the 
rete Malpighii. They may or may not contain capillary blood- 
vessels. According to Robinson, the majority of the papilla? 
containing these corpuscles have no bloodvessels. 

The number of tactile bodies varies in different regions of the 
body ; they are most numerous upon the fingers, especially upon 
the last phalanges. They are found also upon the palms and 
soles, as well as upon other portions of the body. Meissner, who 
devoted much time to their study, ascertained that out of four 
hundred papilla? upon a square line of skin of the last phalanx 
of the finger, one hundred and eight were provided with tactile 
bodies. The same investigator states that they vary from 4^'" 
(.1058 mm.) to T \ f " (.2116 mm.) in length, and that they measure 
about T y" (.0529 mm.) in width. 

PACINIAN CORPUSCLES. 

Pacinian corpuscles (so named after Pacini, an Italian anato- 
mist), alsb called corpuscles of Vater,J are large, firm, well-defined, 
ovoid bodies, found upon the cutaneous nerves. They occur in 
various regions, but are most numerous about the palms and soles, 
and about the fingers and toes, especially on the last phalanges. 
They are found typically developed and most numerous in the mes- 
entery of the cat. They vary in size, averaging from \'" (1.058 
mm.) to 2'" (4.232 mm.), and have their seat in the subcutaneous 
connective tissue. 

Each Pacinian body is connected with a nerve trunk by means 
of a medullated nerve fibre, which enters the corpuscle at its lower 

* Archiv fur Mikroscopisclic A nut , 1873, p. 730. 

f Jour, of Anat. and Phys., 1874, p. 30. 

X According to Lunger, the}' were first described by Yater. 



ANATOMY AND PHYSIOLOGY. 



35 



extremity and passes through the centre of the structure, termi- 
nating in one of several ways to be mentioned. According to 




Fig. III. — Section of a Pacinian Corpuscle (drawn according to the views of 
Schafer), showing a medullated nerve fibre entering the corpuscle at its lower 
extremity, the capsular envelope, the core, and the central fibre. 

Biesiadecki,* a bloodvessel of considerable size enters the cor- 
puscle in the vicinity of the nerve fibre, and forms a plexus 
between the outer layers of the capsular envelope. 

The intimate structure of the corpuscle, according to Klein and 
Smith,f Key and E,etzius,| and Schafer,§ may be regarded as con- 
sisting of three parts, — the central fibre, the core, and the capsular 
enclosure. The central fibre, a continuation of the entering nerve, 
retains a uniform calibre throughout the body until it reaches its 
distal extremity, where it usually becomes enlarged, terminating 
either in the form of an irregularly sized and shaped enlargement, 
or with pointed, fork-like processes. In structure it is composed 
of numerous fibrils, which are observed to cross one another very 
obliquely. The core, situated immediately around the central fibre, 
consists in its innermost portion of a homogeneous, non-nucleated 
substance. Its outer part is composed of protoplasmic cells, like 
connective-tissue corpuscles, each with a clear, oval nucleus. The 



*Loc. cit., p. 233. f Loc. cit. 

t Arehiv fur Mikroscop. Anat., Bd. ix., 1873; see also the superb work, 
Studien in der Anatomie des N/ervensystems und des Bindegewebes. Zweite 
Halfte, Stockholm, 1876. 

\ Quar. Jour, of Micros. Science, April, 1875. 



36 ANATOMY AND PHYSIOLOGY. 



ca 



psular envelope, which surrounds the core, gives form and bulk 
to tlif corpuscle, and is made up of a great number of capsules 
placed iu a concentric manner around a central elongated clear 
mass; it shows, therefore, a concentric striation, each stria corre- 
sponding t<> a capsule, seen in profile. Each capsule is made up 
of time parts: (a) a hyaline ground membrane, probably elastic ; 
(A) in this ground membrane are embedded line connective-tissue 
fibres, arranged either regularly in one or two layers, or irregu- 
larly, but always in a transverse manner; (c) on the inner surface 
of the ground membrane is an endothelial membrane, composed 
of a .-ingle layer of flattened nucleated epithelial cells. The inner- 
most layers of the corpuscle are compactly arranged one upon the 
other, while the more external coats are thicker and less closely 
held together. Viewed as a whole, the Pacinian body is to be 
looked upon as one of the forms of medullated nerve-fibre termi- 
nation. 

Non-Medullated Nerves. — The researches of Langerhans,* Pod- 
copaew,t Klein,| and others, prove that minute nerve branches 
containing one, two, or more nerve fibres, when approaching the 
surface epithelium are connected into a plexus, which is called 
the sub-epithelial plexus. From this small groups of minute 
varicose elementary fibrils come off, which lie close to the under 
surface of the rete Malpighii, and after having formed a net-work 
with large meshes — the sub epithelial network — enter the rete 
Malpighii, where they ascend, always between the epithelial cells, 
towards the stratum lueidum. The exact mode of termination 
has not been defiuitely determined. It thus appears that a dis- 
tinct nervous plexus exists between the rete mucosum and the 
proper laminate epithelium. 

Of the vaso-motor nerves of the skin but little is known with 
any degree of certainty. They are probably of two varieties, those 
connected with the central nervous system and those connected 
with ganglionic plexuses in the immediate neighborhood of the 
skin itself. They exert an influence upou the vascular, muscular, 
and glandular cutaneous systems, causing increase or diminution 
of the circulation, as in flushing and blanching of the surface, 

* Virchow's Archiv, Bd. xliv., 2 and 3 Heft. 
f Archiv fur Mikroscop. Anat. Bd. v., 18G9. 
X Loc. cit. 



ANATOMY AND PHYSIOLOGY. 37 

contraction of the muscles, as in cutis anserina, or when the hairs 
"stand on end," and profuse sweating, local or, more rarely, 
general. Each of these phenomena may arise from external in- 
fluences applied to the surface, or they may be the result of 
internal causes, physical or emotional. 

MUSCLES. 

We encounter both striated and smooth muscular fibres in the 
skin. The former are found only in certain regions of the body, 
as the face. These arise from the deeper-seated muscles, pass up- 
wards vertically or obliquely, and terminate in the corium. The 
smooth muscular fibres exist either as anastomosing plexuses 
running horizontally, as in the scrotum, or as fasciculi, as in 
connection with the hair-follicles, and also the perspiratory and 
sebaceous glands of the skin. As arrectores, or erectores, pill, or 
erectors of the hair, they occur in the form of bands, composed of 
one or of several bundles, which arising from the internal sheath 
of the hair-follicle, pass obliquely upwards, below, and around the 
sebaceous gland, and terminate in the upper part of the corium. 
The evacuation of the sebaceous glands is doubtless performed by 
the contraction of these muscles. Many hairs possess two muscles, 
which pass around on either side of the gland. 

The muscles of the skin exist quite generally over the body, 
and are found to be highly developed upon the scalp, scrotum, 
and penis. The investigations of Kolliker show that they are 
arranged in circular layers about the areola of the nipple, be- 
coming more marked from without inwards as far as the base 
of the nipple. In the nipple they form a close net-work. Con- 
traction of these muscles causes the condition known as cutis 
anserina, or " goose-flesh." 

PIGMENT. 

The general coloration of the skin depends upon a deposition 
of pigment, or coloring matter, in the cells of the mucous layer of 
the epidermis. One or more strata of the mucous layer may be 
the seat of pigmentation. It consists in a slight staining of the 
cells themselves, with a more intense coloring of the nuclei, and 
also in the presence of fine granules of pigment in the cells, ap- 
pearing as a dark line above the papillary layer of the corium. 



38 ANATOMY AM) PHYSIOLOGY. 

The color of the skin varies from white to bluek in different 
races. It also varies from a light to a dark shade in different 
individuals of the same race, giving rise to the hue of persons 

designated bl les and brunettes. Jn certain regions of the body 

the .-kin is always relatively darker in color; as upon the scrotum, 
labia majora, perineum, nipples, and areolae. This difference is 
due -imply to an increase in the amount of the ordinary pigment, 
which is found to be largely developed in these localities. In the 
white race the pigment cells are for the most part yellowish-white 
in color, which, together with the vascularity of the corium, gives 
the peculiar pinkish flesh tint of the skin. In the colored races 
the pigment layer is very highly developed, the whole of the 
mucous layer being more or less stained. The deepest strata of 
cells are always the most intensely colored. In these cases the 
horny layer of the epidermis is also somewhat darkened in hue. 

SWEAT GLANDS. 

The sweat, or sudoriparous, glands (gland ulae sudoriferss) are 
convoluted bodies, situated in the subcutaneous connective tissue. 
They are simple tubular glands, coiled into a more or less globular 
form, surrounded and held together by loose connective tissue, and 
open on the surface of the skin by means of a narrow canal, 
called the excretory duct. This duct begins at the gland and 
ascends in a perpendicular or oblique direction through the skin 
and epidermis, with a straight or slightly wavy course, passing 
between the papillae of the corium, and opening out upon the 
surface of the epidermis. Where the epidermis is thick, as it enters 
and passes through the horny layer it inclines to assume a spiral 
course. In other places it is only slightly spiral or straight. It 
finally terminates in a funnel-shaped aperture, or pore. Upon the 
palms and soles the pore- are quite large, and can at times be seen 
with the naked eye. The ducts vary in length according to the 
locality of the gland. The gland itself is a small, roundish body, 
yellow in color, varying in size as it occurs in one region or an- 
other of the body. In the axilla, where they form an almost con- 
tinuous layer under the corium, they are found to be larger than 
anywhere else, and attain a diameter of \'" (1.058 mm.) to W" 
(3.174 mm.). In other portions of the body they measure about 
\'" (.3526 mm.). The length of the untwisted tube has been 



ANATOMY AND PHYSIOLOGY. 39 

estimated* to average about one-fourth of an inch, which would 
give a total length of over forty thousand feet, or nearly eight 
miles, of perspiratory tubing. 

They exist, according to Horschelmann,f in all parts of the 
skin. According to Klein and Robinson, they are absent on the 
glans penis and on the margin of the lips. In most regions they 
are uniformly distributed. They are very numerous, their num- 
ber being estimated by Krause as 2,381,248.;)] Taking the whole 
surface together, the average number of the glands is 1000 to the 
square inch ; but they vary greatly in different parts of the body, 
counting from 417 to the square inch on the neck, back, and but- 
tock, where they are least plentiful, to 2685 on the sole of the 
foot and 2736 on the palm of the hand. They are extensively 
supplied with bloodvessels, which envelop them completely in 
a reticular manner. Muscles are found in. connection with all 
perspiratory glands, except, according to Horschelmann,§ those 
of the scalp. 

The duct of the gland, following Klein, consists of a narrow 
canal, lined with a bright homogeneous or nucleated membrane 
staining well in carmine ; upon this is found the epithelium, com- 
posed of two or three layers of small polyhedral epithelial cells 
each with a spherical or oval nucleus. Outside of this exists a 
delicate membrana propria. The lumen of the duct is distinct 
and is in most places cylindrical. About one-third or one-fourth 
of the coiled tube retains the same structure as the excretory duct ; 
but the remainder, or the distal part, is of a different nature, the 
lining membrane of the lumen being reduced to a very delicate 
film. The epithelium, which in the duct consisted of two or three 
layers of small polyhedral cells, is here replaced by a single layer 
of columnar, longitudinally striated cells, each with a spherical 
nucleus in the outer part of the cell. The membrana propria of 
this section is, however, much thicker than in the former, and con- 
tains on its inner surface, that is, the one next the epithelial cells, 
a single and continuous layer of very slender unstriped muscle 
cells arranged parallel to the long axis of the tube. 

The diameter of the tube of the gland is, as a rule, greater than 

* Piffard, Diseases of the Skin, New York, 1876, p. 15. 
f Inaug. Diss., Dorpat, 1875. Cbl. f. Med., No. 11, 1876. 
X Kolliker, loc. cit., p. 125. \ Loc. cit. 



40 ANATOMY AND PHYSIOLOGY. 

that of the duct, and in some localities, as in the axilla?, palms, 
and soles, becomes greatly developed. In addition to the con- 
nective tissue holding the coils of the gland together, numerous 
capillary bloodvessels, lymphatics, and a few fat cells are found 
here. 

The sweat glands in the earliest stages, according to Klein, are 
solid projections of the stratum mucosum into the corium. Ac- 
cording to the views of Heitzmann,* however, they are elonga- 
tions of the outer epithelial layers downwards into the corium. 
This takes place about the fifth month of foetal life. Later these 
rudiments grow into the subcutaneous tissue, where they begin to 
coil, this occurring between the seventh and ninth months. 

According to Roehrig,f there are no nerves connected directly 
with the sweat glands. The secretion is forced out by means of 
contraction of muscles situated about the glands, or, in the case 
of the smallest glands, which have no muscles, by the general 
muscular contraction of the skin. 

The secretion of the glands varies in quality according to their 
size and situation. The smaller ones give forth a clear, trans- 
parent fluid, while the larger ones produce the same fluid together 
with fat cells and numerous fine granules with free nuclei.! This 
latter product is to be regarded as coming from the walls of the 
gland tubes. As the rete Malpighii contains a large quantity of 
fluid, and the horny layer, properly so called, is very coherent, 
these layers derive nothing from the perspiration ; but the most 
superficial layer, the pulverulent furfuraceous or porous horny 
layer, collects a large quantity in its interstices. ■ The perspira- 
tion, as it reaches this point, resembles a river lost in the sands, 
nearly all the fluid disappearing. § It is this fact which causes the 
perspiration given off under ordinary circumstances to remain in- 
sensible to the eye, and it is only when this secretion is poured 
out very abundantly that it wells up to the surface in distinct 
drops. 

Sweat has a peculiar odor, varying in different parts of the 
body and in different individuals, a saline taste, and usually an 
acid reaction. Triimpy and Luchsinger|| have come to the eon- 

* Loc. cit. f Loc. cit., p. 65. X Kolliker, loc. cit., p. 127. 

\ Kiiss and Duvall's Physiology, Amer. edition. 
|| Pfluger's Archiv, Bd. xviii., p. 494. 



ANATOMY AND PHYSIOLOGY. 41 

elusion that it is in itself really alkaline, the acid reaction usually 
found on applying litmus paper to the skin being due to decom- 
position of the sebaceous secretion. Unna,* on the other hand, 
considers it a mixed fluid, derived from different sources, its 
reaction varying according to its composition, the view which 
appears to me to be the most plausible. Its reaction, however, is 
variable, depending on circumstances. As Unna states, it has not 
been shown that the sweat which exuded from sweat pores comes 
exclusively from the sweat-coils. The watery element of the sweat 
must in part be drawn from bloodvessels of the papillary layer; 
perhaps also from those surrounding the duct, and from the rete, 
there being, according to Unna, free communication between the 
inter-epithelial spaces of the prickle-cell layer and the lumen of the 
duct. It is composed almost entirely of water, containing less 
than two per cent, of solid materials, of which two-thirds consist of 
organic substances. The inorganic solids are composed chiefly of 
the chlorides, sulphates, phosphates, and carbonates of potassium 
and sodium, with earthy phosphates. Ammonia is probably not 
present in sweat except as a product of decomposition. The or- 
ganic constituents of sweat, as stated by Roehrig, are chiefly urea, 
and formic, acetic, lactic, and possibly other organic acids. To the 
presence of these acids is due the peculiar odor of the secretion. 
In addition, the neutral fats margarin and stearin and also cho- 
lesterin are present. It is classed as an excremential fluid by 
Robin and other physiologists. In particular diseases the sweat 
may become variously colored, as in chromidrosis ; or impregnated 
with different organic matters, as urea (in uridrosis), albumen, 
bile, sugar, etc. Certain substances introduced into the blood are 
excreted by the perspiration. Such, for example, are iodide of 
potassium, and benzoic, succinic, and tartaric acids. The amount 
of sweat excreted is ofteu in inverse proportion to the amount of 
urine carried off by the kidneys. That these glands frequently 
aid and relieve the kidneys admits of no doubt. The per- 
spiratory secretion is also to be viewed in the light of a regu- 
lator of the temperature of the body by its evaporation upon the 
surface. 

The secretion of sweat has received attention at the hands 

* Brit. Med. Jour., Oct. 1, 1881. 



42 ANATOMY AND PHYSIOLOGY. 

of Adamkiewicz* and Unna.f The former investigator regards 
sweating as a bilateral symmetrical nerve function, and believes 
that the glands belong to the same category as the salivary and 
lachrymal glands. Nerve physiology has shown that the secre- 
tion is independent of blood pressure and of the rapidity of the 
circulation, but not of the circulation as a whole. The most 
plausible theory, as Unna states, is that derived from a vaso-motor 
and musculo-motor hypothesis, which explains the action of the 
involuntary muscles connected with the gland, the remarkable 
transitions between fatty, mucoid, and pigmented sweat, and cold 
sweat. 

SEBACEOUS GLANDS. 

The sebaceous, or sebiparous, glands (glandulae sebiparae) are 
situated in the corium, never being found as far down as the sub- 
cutaneous connective tissue. In connection with large hairs they 
lie about on a level with the middle third of the hair-follicle. 
They are met with upon all portions of the body. Thev arc ab- 
sent on the palms of the hands, soles of the feet, dorsal side of 
the last phalanges of the digits, and the glans penis. As a rule, 
they are connected with the hair-follicles, into which they empty 
their secretion. With large hairs this takes place at an acute 
angle at the neck of the follicle. In certain localities, where the 
glands are large, as the labia majora, prepuce, corona of the glans 
penis, scrotum, and nostrils, the ducts of the glands open upon the 
surface of the epidermis. When of small size, the glands appear 
as a growth from the hair-follicle to which they are attached. 
When of large size, the hair would seem to be an appendage of the 
gland. Their size is variable, being from ■£$'" (.2116 mm.) to V" 
(2.116 mm.) in diameter. The largest are those of the eyelids 
(Meibomian glands), nose, cheeks, scrotum, labia, and about the 
anus. Large glands also exist abundantly in the scalp, each hair 
being, as a rule, supplied with two glands. About the scrotum, 
pubes, mons veneris, and labia majora, they are even more numer- 
ous, as many as four or six often being connected with one hair. 

They consist of a gland proper, or the secreting portion, and 
an excretory duct. The gland itself is an acinous, or racemose 

* Die Secretion des Sclnvoisses. Berlin, 1878. 
f Abstract in Brit. Med. Jour., Oct. 1, 188L 



ANATOMY AND PHYSIOLOGY. 43 

one, being made up of a variable number of lobules. Robinson 
gives the formation and minute anatomy of the gland as follows. 
The gland proper is formed of a basement-membrane, or sac, ex- 
ternally, and secreting cells, or their products, internally. The 
basement-membrane is continuous with the transparent membrane 
described as lying directly beneath the rete Malpighii and above 
the corium, and has a similar structure. This basement-membrane 
passes from the sebaceous gland to the hair-follicle, where it forms 
the inner layer of the hair-sac. The membrane of the sebaceous 
gland is surrounded externally by bands of dense connective 
tissue containing bloodvessels, nerves, and lymphatics. The se- 
creting part of the gland is composed of layers of cells similar to 
the cells of the epidermis, those of the outer part correspond- 
ing to the cells of the rete mucosum. The first layer of cells, 
or that seated upon the basement-membrane, is made up of dis- 
tinctly nucleated cylindrical cells, like those of the rete. Farther 
inward the cells are larger, polyhedral in form, and contain fat 
which conceals or obscures the nucleus. If the fat, however, be 
extracted, the nucleus can be seen. The nearer the centre of the 
gland, the greater the amount of fat in the cells. In the centre 
of the gland free fat, fat crystals, and the remains of epithelial 
cells are found. 

The structure of the duct is similar to that of the gland. 
Externally is the basement-membrane, lined inside by epidermis- 
like cells, containing more or less fat, and enclosing a central 
cavity, or canal, through which the sebum flows. Internal to the 
polyhedral cells of the duct are the cells of the corneous layer of 
the epidermis, which diminish in number as the free surface is 
reached. The formation of the gland begins at the third month 
of foetal life, as a projection downwards and outwards of a part 
of the external root-sheath of the hair, at the point of the future 
opening of the duct. 

The product of the secretion of the sebaceous glands is known 
as sebaceous matter, or sebum. It consists of an oily, semi-fluid, 
amorphous substance. In chemical composition it is found, ac- 
cording to Roehrig, to be composed of about 50 per centum of 
fatty matter (olein and palmatin), which is oily at the ordinary 
temperature of the body, but hardens into a tallow-like substance 
on exposure to the air. It is always mixed with numerous cells 



44 ANATOMY AND PHYSIOLOGY. 

derived from the walls of the glands in a state of fatty degenera- 
tion. Besides this, there are in addition a certain quantity of 
saponified fats, some cholesterin, extractive matter, an unknown 
albuminous substance, earthy phosphates, alkaline chlorides, and 
phosphates. Soluble salts are present only in the smallest quan- 
tities. 

It is impossible to estimate the entire amount of the secretion 
of the sebaceous glandular system. The uses of this product of 
the glands are manifold. It serves to give softness and pliability 
to the skin and to the hair. It prevents too rapid evaporation 
from the general cutaneous surface and the consequent effects of 
sudden changes in the temperature of the body. At the same 
time it hinders too rapid desquamation of the epidermis, as well 
as injurious maceration of this layer of the skin by the perspira- 
tory secretion. Thus, we find that in the axilla, where the sweat 
glands are active, the sebaceous glands are present in unusual 
numbers. Upon the palm and sole, where the sebaceous glands 
are absent, the sweat glands appear to secrete, as Roehrig states, a 
certain amount of oily matter together with the perspiratory fluid. 

HAIPvS. 

Hairs are fine, long, rounded, compact bodies, having their seat 
in depressions in the skin, the so-called hair-follicles. Three 
kinds of hair are recognized: long hair, as that of the scalp; 
short, thick hair, as that of the eyebrows; and very fine, soft hair, 
called lanugo, found upon the face, trunk, and other regions. 

In considering the hair we distinguish two portions, namely, 
the shaft, which is free, and protrudes beyond the surface of the 
skin, and the root, the part contained within the skin. The shaft 
is usually long and straight, tapering off to a point as it approaches 
its end, while the root is found to be thicker and to terminate in a 
bulb-shaped expansion, termed the hair-bulb. The root of the 
hair, within the follicle, consists of the hair-substance, the cuticle, 
and the inner root-sheath. In minute structure the hair consists 
of the hair-substance and the cuticle ; another portion, the medul- 
lary substance, may also be mentioned, although its presence is 
not constant. 

The hair-substance, termed also cortical substance, constitutes the 
bulk of the hair, and is composed of a number of long, narrow, 



ANATOMY AND PHYSIOLOGY. 45 

spindle-shaped filaments or bundles, longitudinally striped, con- 
taining pigment granules, which give it a punctate appearance. 
These filaments are further made up of long, faintly nucleated 
cells, or scales, which adhere so closely together as to be separable 
only by the employment of caustic alkalies or strong acids. Be- 
tween these scales, in colored hair, rows of minute pigment gran- 
ules, varying in color and in quantity, are found. When not 
abundant, these pigment granules are not contained in the scales, 
but in the interstitial substance between them. In addition to 
the pigment granules the scales are diffusely pigmented. In white 
hairs the hair-substance is without pigment, and is transparent, 
and, according to Klein,* contains between the hair scales the finest 
air-bubbles. According to the views of Heitzmann,f the hair is 
to be regarded as a solid elongation of the internal root-sheath, 
the external root-sheath taking no part in its formation. 

The hair-bulb, or root proper, surrounds the hair-papilla at the 
base of the follicle. It is a loose, spongy structure, and is com- 
posed of nucleated cells similar to those found in the deep strata 
of the mucous layer of the epidermis. Small granules, either 
colorless or pigmented, according to the color of the hair, are 
present, and give the structure a speckled appearance. At the 
point where the hair-bulb joins the straight portion of the root, 
the cells composing the bulb pass imperceptibly into the fibre cells 
of the cortical substance. 

The cuticle is a very delicate membrane, which completely in- 
vests the hair-substance and serves to bind its bundles more firmly 
together. It ensheathes both the shaft of the hair and the root. 
It begins on a line with the neck of the papilla. The cells are at 
first round, then larger and columnar, with large and distinct 
nuclei, and finally in the root and shaft elongated, thin, and im- 
bricated, and without nuclei. Upon the shaft, where the cells 
overlap one another, it presents a reticulated, serrated appearance, 
not unlike that of the scales upon a fish. When treated with 
alkalies it becomes detached from the hair-substance, and consists 
of flat, transparent cells, or scales, without nuclei. They are 
analogous to the cells of the horny layer of the epidermis, and 
serve a like purpose. 

* Loc. cit., p. 319. f Chicago Med. Jour, and Exam., Dec. 1881. 



46 



AX ATOMY AND PHYSIOLOGY. 



The medullary substance, or medulla. is wanting in some hairs. 
It is usually present in the short and thick hairs, as well as in the 
long hairs of the scalp; it is absent in lanugo. When present 





'■Vn/4 


r t \i; 


''!■'. W H a ' 




'^ : -$:Ah' 


'"■:?.:■/:•■ K"P 


ft 7 1 


H 


R-'-Jii'' 






% 



b vm 



Fio. IV.-Tiik IIaiii am, thb Haib-Folwclk. A, Shaft of the hair. B, Root 
of the hair. C, Cuticle of the hair. L>, Medullary substance of the hair. 

E, External layer of the hair-follicle. F, Middle layer of the hair-follicle. G, 
Internal layerof the hair-follicle. II, Papilla of the hair. T. External root-flheath! 
J, Outer layer of the internal root-sheath. K, Internal layer of the interna] root- 
Bheath. 

it is seen as a broad, colored line or cord, running longitudinally 
tli rough the centre of the hair, commonly extending throughout 
.its whole length. In structure it consists of one, two, or three 
rows of cells, polyhedral or oblong in shape, containing spherical 
nuclei and fatty granules. Thev may be seen to advantage with 



ANATOMY AND PHYSIOLOGY. 47 

the aid of strong alkalies or strong acids. Minute air-vesicles are 
frequently found in the medullary substance. According to Klein, 
they exist here normally, appearing black in transmitted light. 

HAIR-FOLLICLE. 

The hair-follicle is an elongated sac, dipping down into the 
corium and subcutaneous connective tissue, for the accommodation 
of the hair. It is to be viewed as a continuation of the papillary 
layer of the corium. It is cylindrical in form, tending to enlarge 
at its lower extremity. Its upper portion, termed the mouth, is 
funnel-shaped, and opens directly upon the free surface. Imme- 
diately below this is a constriction, called the neck, which is the 
narrowest part of the follicle. This is just below the level of the 
papillary layer of the corium. The duct of the sebaceous gland 
enters at this point. The follicle now enlarges somewhat, con- 
stituting the body, and finally terminates in a bulbous extremity 
accommodating the hair-papilla and the bulb of the hair. The 
hair-follicle is always placed more or less obliquely in the skin, 
usually in the form of a straight line, but it is sometimes slightly 
curved, as on the lips and eyebrows. 

The calibre and the length of the hair-follicles vary greatly in 
different regions and localities. They average from V" (2.116 
mm.) to 2>'" (6.348 mm.) in length. Upon the scalp they are 
likewise variable as to size, and occur in groups of three or four. 
The hair-follicle contains the hair and the external and internal 
root-sheaths. 

According to Heitzmann,* the horny layer of the epidermis, 
which proceeding downwards results in the formation of the in- 
ternal root-sheath, upon entering the follicle is at about the middle 
of the follicle gradually reduced to not more than two strata. 
Near the bottom of the follicle the inner root-sheath gains in 
width, and is composed of three or four strata of epithelia, which 
have now lost their horny character and have become of a proto- 
plasmic nature again. The rete mucosum enters the follicle in its 
full width, but gradually becomes composed of a smaller number 
of epithelia, which retain their original protoplasmic character, 
and near the bottom of the follicle completely disappear. In 

* Chicago Med. Jour, and Exam., Dec. 1881. 



48 ANATOMY AND PHYSIOLOGY. 

structure it consists of three layers, the external, the middle, and 
the internal. 

The external layer (termed by Kolliker the external fibrous coat) 
determines the form of the follicle; it is the most important 
and thickest layer, and consists of connective-tissue fibres which 
run parallel with the course of the hair, blending above in the 
papillary layer with the fibres of the corium, and terminating 
below, around the hair-bulb, in the form of an ovate prolonga- 
tion into the subcutaneous connective tissue. The external por- 
tion of the layer merges into the surrounding connective tissue. 
It is supplied with an artery, a vein, and a medullated nerve 
fibre. 

The middle layer (the internal fibrous coat of Kolliker) is less 
extensive than the external layer, and is made up of transverse 
connective-tissue fibres, with oval nuclei, embedded in a granular 
substance. These latter are regarded by Klein and Heitzmann as 
cross-sections of smooth muscle fibres. They are seen to best 
advantage about the bulbous portion of the follicle. Bloodvessels, 
in the form of a close net-work of capillaries, have been found 
here, but as yet no nerves. 

The internal layer (called also hyedine or vitreous membrane, and 
structureless membrane) is not acted upon by either acids or alkalies. 
It is a homogeneous, transparent tissue. Its outer surface is 
smooth ; its inner surface is marked with delicate transverse lines. 
Although homogeneous on section, it shows, according to Biesia- 
decki, when viewed on the flat surface, transverse, oblique, decus- 
sating fibres, together with ill-defined nuclei. It is thin near the 
mouth of the hair-follicle, increases in thickness towards the distal 
part, reaching its greatest thickness near the bulbous extremity, 
and becomes again thinner as it approaches the papilla. Over this 
latter it exists only as a very delicate membrane. It is a direct 
continuation of the basement membrane of the corium. It is 
without bloodvessels or nerves. 

At the base of the follicle rises the hair-papilla, an ovate, club- 
shaped or spherical, well-defined body, about yV" (•I'llO mm.) 
long, which protrudes into the hair. It has a narrow neck and a 
thicker body. It is about twice as long as it is broad. It springs 
from the connective tissue of the follicle, and consists of connec- 



ANATOMY AND PHYSIOLOGY. 49 

tive tissue together with round nuclei and nucleated cells. It is 
separated from the root of the hair by the internal layer of the 
hair-follicle. It contains one or more arteries, veins, and also 
non-medullated nerve fibres. 

There are two root-sheaths, an external and an internal ; they 
are made up of a number of layers. 

The external root-sheath is simply a continuation of the mucous 
layer of the epidermis, which extends down the hair as far as the 
bulb. It is composed of stratified epithelial cells, the outermost 
layer being columnar. As it approaches the bulb the rows of 
cells become fewer, and the layer consequently narrower, finally 
terminating in a single row of columnar cells. The last, or 
single, row of cells is columnar in form, being the continuation of 
the outermost layer referred to. It disappears at the beginning 
of the bulb. On the outside it adjoins the vitreous membrane 
of the follicle, which membrane, or layer, also above separates 
the external from the internal root-sheath. Langerhans claims 
to have found nerve structure here, the same as in the mucous layer 
of the epidermis. 

The internal root-sheath is traced from the orifice of the hair- 
follicle downwards, and is composed of two epidermal layers, an 
outer layer (known also as Henle's sheath) and an inner layer 
(called Huxley's sheath). Following the observations of Heitz- 
mann,* at the bottom of the hair-follicle the inner root-sheath 
becomes wider, turns over, surrounds the papillae, and constitutes 
the bulb of the root of the hair. Later, it forms the root and 
then the shaft of the hair. The innermost layer of the inner 
root-sheath by reflecting results in the formation of the cuticle. 
The cells of the lower portion of the inner root-sheath are coarsely 
granular, indistinctly nucleated, and elongated. Farther up they 
are finely granular, pale, with indistinct nuclei. The cells of the 
outer, or Henle's, layer, lose their nuclei sooner than those of the 
inner layer, and are polyhedral or elongated, highly-refractive 
looking bodies. Farther up the root the cells of the two layers 
— Henle's and Huxley's — become indistinguishable. The cells 
now have the character of horny epithelia. 

Concerning the shedding of the hair, it may be stated that the 



* Loc. cit. 
4 



50 ANATOMY AND PHYSIOLOGY. 

young hair is formed around the old papilla. At a certain dis- 
tance above the papilla there appears a club-shaped thickening, 
which corresponds to the bulb of the hair being cast off. Accord- 
ing to Heitzmann, the new growth of a hair takes place within 
the province of the internal root-sheath exclusively. As was first 
suggested by Biesiadecki, the smooth muscles also play a part in 
the shedding of the hair, their contraction causing a neck to be 
formed around the young hair. 

Hairs occur upon all parts of the body, except the palms and 
soles, eyelids, backs of the last phalanges of the fingers and toes, 
lips, and inner surface of the prepuce and glans penis. They are 
seated in the skin in a more or less oblique direction, varying 
with the region of the body. They vary both in thickness and 
in length, according to locality : they are shortest and finest in the 
delicate lanugo found upon the face and trunk, and longest and 
coarsest upon the scalp and beard. The number of hairs upon 
the body likewise varies considerably in different localities; also 
in different individuals. As a rule, the lighter the hair in color 
the more numerous will they be found. Wilson* calculates the 
number of hairs of the scalp to be about one thousand to the 
square inch, or one hundred and twenty thousand to the whole 
scalp; other calculators make the number less. The difference de- 
pends upon the number of follicles present; also upon the number 
of hairs arising from each follicle. As a rule, there is only one 
hair in each follicle, but often there are two. The direction of 
the hairs for the different regions has been elaborated by Yoigt.f 
They run in peculiar lines and curves, which in certain places, as 
on the crown of the head, form circles, segments of circles, or 
" whirls." The cause of this plan of arrangement is found in 
the direction of the bundles of connective tissue of the corium, 
as has been shown by Tomsa.J 

The general color of the hair varies extremely in different races 
and in individuals. It depends upon the presence of pigment in 
the hair-filaments, in the form either of granules or of a diffused 
coloration. It is also influenced by the presence of minute air- 



* Lectures on Dermatology. London, 1878, p. 99. 

f Quoted by O. Simon, loc. fit, p. 19. X Loc. eit. 



ANATOMY AND PHYSIOLOGY. 51 

vesicles, which may occur, Biesiadecki thinks, either between the 
cortical and medullary substances or in their interior. 

Hairs are remarkably elastic, and admit of great extension ; 
they are also very strong, and are capable of supporting con- 
siderable weight without breaking. When cut, they grow again 
until they have assumed their determinate length. The rate of 
the growth of the hair of the head is about six lines a month. 
It grows more rapidly in youth than in age, and in summer than 
in winter. Frequent cutting of the hair promotes its growth, as 
has been shown by Berthold, and more recently by Moleschott.* 
Hairs absorb and give off water readily ; they also take up fatty 
and oily substances. In structure they contain no bloodvessels ; 
they are nourished from their papilla?. In chemical composition 
they consist of a nitrogenous substance containing sulphur, fat, 
pigment, and mineral salts. They retain their characteristics for 
a very long time, and are the last portion of the body to give way 
to decomposition. 

NAILS. 

The nails are hard, horny, elastic, transparent structures, which 
are embedded in the skin upon the last phalanges of the fingers 
and toes. They are rounded or quadrilateral bodies, and are 
curved from side to side. They have four borders, one of which 
only, the anterior, is free ; the posterior and lateral borders are 
sunk in the flesh. The posterior portion of the nail, situated in 
the skin, is termed the root, while the exposed part is called the 
body. 

Around the lateral and posterior borders of the nail, at the 
point where the skin joins the nail, there exists a well-defined 
groove, called the nail-groove. The corium upon which the nail 
rests is called the bed or matrix; it corresponds in form to the 
nail, to which it is closely adherent. The matrix is a part of the 
corium, and presents peculiar ridges, upon which are seated the 
papilla?, directed somewhat forward. It is a dense tissue, con- 
taining an abundance of elastic fibres and but little fat. The 
bloodvessels form a plexus in the upper part of the corium, sup- 
plying the papilla?, and also a finer plexus in the lower portion, 
devoted to the matrix itself. According to Biesiadecki,f numer- 

* Untersuchungen zur Naturlehre, Bd. xii. f Loc. cit., p. 260. 



52 ANATOMY AND PHYSIOLOGY. 

ous mcdullated nerve fibres lie in the subcutaneous tissue of the 
nail-bed, which, losing their medullary sheath at about the level 
of the corium, run vertically to the surface. A defined, whitish 
substance, surrounded anteriorly by a convex line, is usually 
present in the matrix, just in front of the posterior groove. It 
is crescentic in shape, and is called the scmilunula or lunula. 

In structure the nail must be regarded as modified epidermis. 
Like it, it is divided into two layers, a horny and a mucous layer. 
The former constitutes the greater portion and substance of the 
nail, forming its exterior as well as its free edge. The surface is 
smooth and glistening, and contains longitudinal striie, which are 
parallel, running from the root to the free edge. In order to 
study the intimate structure of the nail it is necessary to employ 
strong acids or strong alkalies. It is then found to be made up 
of numerous closely connected plates, which may be further re- 
solved into polygonal, flat cells, resembling those of the horny 
layer of the epidermis. 

The nail, like the hair, grows more rapidly in summer than in 
winter. It also grows more rapidly in children than in adults. 
It begins to form in the third month of intra-uterine life, and at 
the eighth month is well developed. 



SYMPTOMATOLOGY. 

Diseases of the skin exhibit themselves in the form of symp- 
toms, which are either of an objective or of a subjective nature. 
Objective symptoms are those which consist of certain appear- 
ances which manifest themselves upon the surface, and are for the 
most part the result of structural alteration in the tissues. They 
comprise the external forms of disease, and are consequently capa- 
ble of ocular demonstration. Here are found both the primary 
and the secondary lesions. Subjective symptoms, on the other 
hand, relate to sensation, of which the patient alone is able to take 
cognizance. 

In addition, symptoms involving the general economy, as mani- 
fested, for example, through the vascular or nervous system, must 
be referred to. Thus, certain acute and grave maladies are accom- 
panied by more or less fever, general debility, or marasmus; in 
other instances disordered digestion or menstruation, or functional 
disturbance of other organs, is noted ; while sometimes organic 
disease is found to exist. All symptoms, indeed, of whatsoever 
character, should in each case receive attentive consideration. 

OBJECTIVE SYMPTOMS. 

Under this head are*, to be studied the various lesions which 
occur in the skin. They are numerous, and are, moreover, capa- 
ble of undergoing many modifications. They may be divided 
into those which show themselves as primary forms of disease, 
termed primary lesions, and those which exist either as the result 
of primary lesions or from other causes, designated secondary 
lesions. The importance of obtaining a just appreciation of these 
morbid changes cannot be over-estimated. Upon their recognition 
depends the ability to establish correct diagnoses. 

53 



54 SYMPTOMATOLOGY. 



PRIMARY LESIOXS. 



MACULES. 

, Maculae; Spots; Germ., Flecke ; Fr., Taclies. 

Macules are variously sized, shaped, and colored portions 
of altered skin, unaccompanied by elevation or depression. 

They are of various sizes; they may be as small as a pin-head 
or as large as a hand. In outline they are usually roundish, but 
they may also be irregular in shape. They are usually circum- 
scribed. In color and tint they vary exceedingly ; they may, in 
fact, be of any color, the more common, however, being reddish, 
yellowish, and brownish. They are the product of diverse causes, 
and consequently represent a number of pathological conditions. 

The simplest variety of macule is that caused by hyperemia 
and called erythema, examples of which are of constant occurrence 
in connection with numerous disorders. 

Maculae may also be the result of hemorrhage into the tissues 
of the skin, when they appear as reddish, bluish, or blackish 
marks, which do not disappear under pressure. Such are met 
with in purpura. Flat vascular or pigmentary growths in the 
skin, as some nsevi, are also included as macules. 

Alterations in the pigmentary function of the skin likewise 
give rise to macules, which may be due to either an increase or 
a deficiency of the normal coloring matter. The disease vitiligo 
offers an instance where the spots are caused by an increase as well 
as a deficiency of the pigment, both atrophy and hypertrophy 
taking place side by side. The yellowish macules termed chloas- 
mata, observed for the most part about the face of women, occa- 
sioned by the presence of an excessive amount of the normal pig- 
ment, may also be mentioned. Another form of the macule, due 
to the same cause, is found in lentigo, or freckle ; still another, 
yellowish in color (due to a vegetable parasite, the microsporon 
furfur), in tinea versicolor. 

When abnormal coloring of the skin involves the whole or a 
large portion of the surface in a uniform manner, the condition 
is designated a discoloration. Examples of this are observed in 
jaundice, in Addison's disease, and in leprosy; also in the staining 
of the skin resulting from the internal use of nitrate of silver. 



SYMPTOMATOLOGY. f)5 

The pigment deposits or stains accompanying or following cer- 
tain diseases, as, for example, lichen ruber and syphilis, may also 
be referred to ; likewise chemical stains, as those resulting from 
the external use of iodine, nitrate of silver, and other substances. 

Macules are evanescent or permanent according to their cause. 
They disappear or remain under pressure, as they are of one kind 
or another. They may or may not be accompanied by subjective 
symptoms. 



Syn. , Papulse ; Germ., Knotehen; Fr., Papules. 

Papules are circumscribed solid elevations op the skin, 
varying in size from a pin-head to a split pea. 

They are of various shapes; some are acuminated, some are 
rounded, while others are flat and angular. They are encountered 
in numerous diseases; are due to a great number of causes; and 
have their seat in different structures of the skin. They may be 
situated in the corium ; in connection with sebaceous glands; or 
about the hair-follicles. They may or may not be inflammatory, 
according to their origin and mode of development. Their color 
varies; they may be reddish, pale or dark in shade, yellowish, or 
whitish. 

Papules are of many varieties, the more prominent of which 
are the following. The commonest is that which consists of a 
small circumscribed plastic exudation in the skin. It finds its 
typical expression in papular eczema. Inflammatory papules may 
or may not undergo metamorphosis into other lesions ; thus, not 
infrequently they pass on into vesicles and pustules, or they may 
break down and become ulcers, as occurs in syphilis. Another 
variety is made up of accumulations of epidermic cells, arranged 
concentrically around the entrances of the hair-follicles, forming 
conical elevations, as in keratosis pilaris. 

Still another kind is formed about the sebaceous glands, consist- 
ing of a circumscribed collection of sebum, producing a small, 
whitish, semi-globular elevation, as observed in milium. Closely 
allied to this formation is that which occurs in comedo, which may 
also be considered as a papule. Finally, hemorrhage into the 
skin may give rise to papules, as in purpura papulosa. 

They may also be formed by hypertrophy of the normal struc- 



56 



SYMPTOMATOLOGY. 



tures of the skin, as the papillae, examples of which may be 
observed in ichthyosis, warts, etc. 

The duration of papules varies with their character, as in the 
case of the other lesions of the skin. They may be acute, chronic, 
or permanent, They may disappear by absorption, as in the case 
of most of the inflammatory varieties, or they may be removed by 
mechanical or other means, as may take place in epithelial mol- 
luscum or in milium. Inflammatory papules are in the course of 
their evolution frequently surmounted by accumulations of fine 
scales, more particularly during the stage of decline. When 
scales are present, the lesion receives the name of a squamous 
papule; this condition is of common occurrence in syphilis. The 
disappearance of inflammatory papules, especially those of long 
standing, is apt to be followed by more or less pigmentary 
deposit, as in lichen ruber. 

Papules may or may not be attended by itching, this symptom, 
as well as others of a like kind, depending upon their nature, and 
also upon the individual. Those of eczema are remarkable for 
the violence of the itching which they occasion, while, on the 
other hand, those of milium or of keratosis pilaris give rise to 
no inconvenience. 

VESICLES. 

Syn., Vesiculse; Germ., Blaschen ; Fr., Vesicules. 

Vesicles are circumscribed, rounded or acuminated ele- 
vations OF THE EPIDERMIS, VARYING IN SIZE FROM A PIN-POINT 
TO A SPLIT PEA, CONTAINING A CLEAR OR OPAQUE FLUID. 

They are of different colors, according as their contents are pure 
serum, sero-purulent matter, or serum mixed with blood. When 
recent and typical in character, they are clear and possess a yel- 
lowish hue. They may be either fully or partly distended with 
fluid ; their walls may be tense or flaccid. As a rule, they rupture 
readily, and discharge their contents over the surrounding surface. 
Certain vesicles, however, as those of herpes zoster and sudamina, 
are tenacious, and do not break unless exposed to violence. 

In form vesicles are rounded, circumscribed, and either possess 
a dome-like roof or are more or less acuminated. They may have 
an even, rounded, or irregular surface, or they may have slight 
depressions on their summits or about their walls. Anatomically 



SYMPTOMATOLOGY. 57 

they have their seat sometimes between the mucous and horny 
layers of the epidermis, in other cases within the mucous layer. 
They may be superficial or deep-seated. They may be single or 
compound, consisting of one or of several chambers; single vesicles 
' are seen, for example, in sudamina ; compound vesicles in herpes 
zoster, and in dermatitis from rhus poisoning. They may also 
coalesce. As a rule, they are inflammatory. They may also be 
due to collections of sweat about the apertures of the gland ducts. 
Vesicles do not remain as such for any length of time ; rarely for 
more than a few days. They either rupture, the fluid becoming 
a crust, or they retain their contents, which are absorbed or pass 
into a purulent condition and thus become pustules. The changes 
which they undergo vary in different diseases, and even in the 
same disease. 

Vesicles rarely occur singly, but almost always in numbers, 
either in the form of aggregations, as in eczema, or in distinct 
groups, as in herpes zoster. They may occur upon all parts of 
the body, more especially upon those regions where the epidermis 
is delicate and soft; but they are also encountered in the palms of 
the hand. They are usually accompanied by burning and itching 
sensations ; at times, however, such symptoms are absent. 

BLEBS. 

Syn., Bullae ; Germ., Blasen ; Fr., Bulles. 

Blebs are irregularly-shaped elevations op the epider- 
mis, VARYING IN SIZE' FROM A SPLIT PEA TO A GOOSE-EGG, CON- 
TAINING A CLEAR OR OPAQUE FLUID. 

They vary exceedingly in size, and have no definite form. 
Large and small blebs may occur simultaneously side by side. 
They may appear either singly or in numbers ; they are rarely so 
numerous as vesicles, nor do they incline to form into groups. 

When recent they are usually of a pale yellowish color ; when 
their contents become turbid, they are whitish or yellowish ; con- 
taining blood they are reddish or brownish, and are often streaked. 
Their fluid is albuminous and offers an alkaline or neutral chem- 
ical reaction. 

Blebs usually possess strong walls, and do not tend to rupture 
spontaneously. As a rule, they consist of a single chamber. They 
are generally distended, often to their utmost capacity ; in par- 



58 SYMPTOMATOLOGY. 

ticular instances, however, they are only partly filled and remain 
flaccid. At times they break before they are perfectly formed, 
leaving their shattered walls attached to the skin in the form 
of shreds; this process, for example, takes place in pemphigus 
foliaceus. 

The walls of blebs usually rise up directly from the surface of 
apparently healthy skin, without, as a rule, marked signs of inflam- 
mation; occasionally areolse are present. Like vesicles, they have 
their seat in the middle or deeper layers of the epidermis. Their 
intimate structure also corresponds to that of vesicles. They are 
not commonly attended by marked itching or burning sensations, 
except sometimes in their early stages, or in those cases where they 
are present in large numbers. In severe pemphigus, however, 
these symptoms are at times very positive. They are encountered 
in pemphigus, pemphigoid eruptions, dermatitis, erysipelas, herpes 
iris, syphilis, leprosy, and occasionally as a complication in other 
diseases. 

PUSTULES. 

Syn., Pustulae; Oerm., Pusteln ; Fr., Pustules. 

Pustules are circumscribed, rounded, flat, or acuminated 
elevations of the epidermis containing pus. varying in size 
from a pin-point to a large finger-nail. 

They either originate as pustules or become so by transition 
from vesicles or papules. Thus, all stages from the vesicle to the 
pustule are encountered, such lesions being designated vesico-pus- 
tules. Inasmuch as they always contain pus, pure or mixed, they 
have a yellowish-white or yellowish opaque color; not infrequently 
they also contain blood, in which event they are dark reddish or 
brownish. 

There are several well-defined kinds of pustule, their chief dif- 
ferences resting in their seat, mode of development, and structure. 
The pustule of acne, for example, has its seat in a sebaceous gland ; 
that of sycosis, about a hair-follicle; that of ecthyma and of pus- 
tular eczema, in the papillary layer of the corium. As a rule, they 
are accompanied with areola?, which are frequently extensive and 
characterized by a high degree of inflammation and at times indu- 
ration. 

Their course and duration vary according to their character; 
they usually incline to a rapid termination. They either burst, 



SYMPTOMATOLOGY. 59 

forming a thick, yellowish, greenish, or brownish crust, or desic- 
cate without rupture, leaving a dry, friable, often bulky crust. 
Pustules may or may not be followed by cicatrices, this depending 
upon the nature of the lesion, and also upon the extent to which 
the process has involved the corium. The scars resulting from 
variola, as well as from acne and from syphilis, are well known. 

Pustules are for the most part unaccompanied by prominent 
subjective symptoms. In some cases burning sensations and pain 
are present, as in sycosis non-paras itica and ecthyma; more rarely 
itching is noted. 

WHEALS. 

Syn., Pomphi ; Urticse; Germ., Quaddeln. 

Wheals are rounded, plat, elongated, ovalish, or irregu- 
larly-shaped, RAISED ELEVATIONS OP AN EVANESCENT CHARACTER. 

Their size varies extremely; they may be as small as split peas, 
the size of a finger-nail, or as large as the palm of the hand. They 
may occur singly, but are apt to appear in numbers, and when 
near to one another exhibit a decided inclination to run together; 
by this process of coalition large surfaces often become involved 
in patches. In form, they ordinarily manifest themselves as bean- 
shaped or ovalish elevations, tending to assume an elongated rather 
than a rounded shape; they also occur in the form of irregular 
lines, bands, or stripes. Their color is usually whitish, rosy, or 
pinkish, often with pale centres, and with more or less marked 
areolae. Sometimes they present a shining aspect. In duration 
they are evanescent, or fugitive; they form rapidly, often in a 
few moments, and, remaining a longer or shorter time, usually dis- 
appear in almost as rapid a manner as they came. Their course 
is capricious. 

They have their seat in the upper layers of the skin, and are 
produced by a sudden effusion of fluid into the meshes of the 
corium, followed by immediate contraction of the capillaries, the 
skin being for the time in a state of spasm. Upon relaxation the 
fluid is absorbed and the wheal disappears. They may contain 
serous fluid, as in simple urticaria, or a mixture of serum and 
blood, as in purpura. The typical wheal is seen in the sting of 
the common nettle ; also in urticaria. They are always accompa- 
nied by tingling, burning, and itching sensations, which are often 
very distressing. 



60 SYMPTOMATOLOGY. 



TUBERCLES. 

Syn., Tubercula ; Germ., Knoten ; Fr., Tubercules. 
Tubercles are circumscribed, firm, rounded or acuminated 
elevations of the skin, varying in size from a split pea to 

A CHERRY. 

In shape they are usually circumscribed, but possess no definite 
form; they may be semi-globular, conical, flat, or of irregular 
outline. Their color is usually reddish : this feature, however, 
depends upon their nature; thus, in molluscum fibrosum they are 
pinkish or flesh-colored. In those cases where they are due to 
inflammatory products or to new formations, they are apt to exhibit 
a brownish-red color. They are ordinarily of firm consistence, and 
have their seat in the corium and subcutaneous connective tissue. 
In minute structure they are similar to papules, frequently being 
in reality exaggerated papules involving deeper tissues and a more 
extended amount of surface. They are the result of various causes, 
as in the case of papules, but are produced in great part by the 
cellular neoplasmata. Syphilis, leprosy, and carcinoma all give 
rise to marked examples of tubercle. They undergo various 
changes in their involution, according to their nature and circum- 
stances ; they are either absorbed or break down and ulcerate and 
are followed by scars, or they may establish themselves and remain 
permanent, as in molluscum fibrosum. 

TUMORS. 

Syn., Tumores ; Phymata; Germ., Knollen ; Fr., Tumeurs. 

Tumors are variously sized, shaped, and constituted, firm 
or soft prominences. 

They are of all sizes, from a pea to an egg and larger. They 
are usually of a semi-globular form, and are either connected to 
the skin with a broad base, as in epithelial molluscum, or are 
pedunculated, as in many cases of molluscum fibrosum. They are 
more or less well defined, according to their nature. Their color 
is often the same as that of the adjacent skin or reddish. They 
rise above the surrounding skin to a variable elevation, and, on 
the other hand, extend more or less deeply into the tissues beneath. 
They are occasioned by a great variety of causes : alterations in 
the sebaceous glands, new formations in the corium, connective 



SYMPTOMATOLOGY. Gl 

tissue, bloodvessels, and lymphatics, all give rise to their develop- 
ment. They may or may not be painful. 



SECONDAEY LESIONS. 

CRUSTS. 

Syn., Crustse; Germ., Borken ; Krusten ; Fr., Croutes. 

Crusts are effete masses of dried material composed of 
the products of disease of the skin. 

They are variable as to size and form, their features depending 
upon the nature of the process which has occasioned them, as well 
as upon the length of time which they have existed; they may be 
large, thick and bulky, or thin and flat. They are adherent to the 
skin or loose, according to their age and the nature of the disease. 
In color they are usually yellowish or brownish; they may also be 
greenish, reddish, or blackish. They are for the most part formed 
by the desiccation of exuded fluids, as serum, pus, and blood. 
Several distinct varieties of crusts are observed. Those resulting 
from an open, serous-discharging surface are yellowish in color, 
friable in consistence, and usually without definite outline or bulk, 
as in eczema ; those following the breaking down of pustules are 
darker, more tenacious, and thicker, as in ecthyma. The crusts 
of syphilis are firmer and less friable in structure, and frequently 
have a heaped-up appearance; they are often greenish in color, and, 
when recent, are seated upon an ulcer. Reddish or blackish crusts 
always contain more or less blood. Sebaceous crusts, as those of 
seborrhoea, are light yellow, dirty yellow, or blackish in color; 
they are flat, lamellated, adherent to their bed, and have both a 
greasy appearance and feel. Another form of crust, that of tinea 
favosa, remains to be mentioned ; here the formation is chiefly 
composed of the parasite, and presents a sulphur-colored, cup- 
shaped, or, if old, an irregularly-shaped mass. 

SCALES. 
Syn., Squamae; Germ., Schuppen ; Fr., Squames. 
Scales are dry, laminated masses of epidermis which have 
separated from the tissues beneath. 

They vary greatly in size and form ; they may be large and 
thick or small and thin; they may be abundant or scanty. In 



62 SYMPTOMATOLOGY. 

consistence they are always dry and of a horny nature; they 
possess a harsh feel, and are more or less brittle, with a tendency 
to separate and to break up into their more minute elements. 
Their color is usually whitish or grayish; at times they are yel- 
lowish or dirty-yellowish. They usually have a shining or glis- 
tening aspect. The quantity formed and thrown off varies with 
the morbid process. With many inflammatory diseases scaling 
occurs as a prominent symptom, the amount and character of 
the inflammation influencing the degree of desquamation. 

Scales are at times formed in large, bulky lamellae or plates, or 
in heaps, as in psoriasis; sometimes in thin flakes, as in pityriasis 
rubra : in other cases, as in dry seborrhcea or in eczema, they con- 
sist of coarse or fine flakes or bran-like particles. They are due 
to a variety of causes. The diseases producing them may have 
their seat in the corium or epidermis, as in the vegetable parasitic 
diseases, or they may be located in the deeper structures, as in the 
inflammatory affections. They are also met with in hypertrophies, 
as in ichthyosis. They are likely to form in all cases in which 
there is want of proper nutrition in the skin, and therefore may 
be the product of numerous pathological changes. 

EXCORIATIONS. 

Syn., Excoriationes ; Germ., Hautabschiirfungen ; Fr., Excoriations. 

Excoriations are variously sized and shaped losses op 
tissue occurring in the superficial layers of the skin. 

Their seat is usually in the epidermis, extending to the mucous 
layer, but not infrequently the papillary layer of the corium is 
involved. They comprise slight wounds and abrasions of the 
skin, lacerations, scratch marks, etc. As a rule, they heal readily 
and without leaving scars. In appearance they present a variety 
of forms, as they happen to have been produced by one or another 
cause. Ordinarily they consist of torn points, lines, or streaks, 
more or less furrowed, with shreds of epidermis variously sized 
and shaped, for the most part irregular, showing reddish, moist 
surfaces, oozing minute quantities of serum and blood which have 
a tendency to dry into crusts. They may be present in connection 
with an eruption of a pruriginous nature, or they may exist inde- 
pendent of disease, as simple wounds of the epidermis produced 
by mechanical causes. 



SYMPTOMATOLOGY. 63 

Scratching;, on the part of the patient, is the direct cause of 
the vast majority of excoriations. The symptoms which give rise 
to the desire for scratching are numerous, and are intimately 
connected with a large number of diseases. All disorders of the 
skin accompanied by nerve irritation, whether from an internal 
or an external cause, occasion more or less itching and consequent 
scratching. If the itching be intense, the scratching usually will 
be violent and the marks proportionally severe and deep ; if 
slight, as a rule, there will be but little and the lesions superficial. 
Excoriations occur most abundantly in eczema, in scabies, and in 
pediculosis. All skins are not affected to the same extent by the 
act of scratching; in some the lesions are readily produced, while 
in others the tissues resist the injury. 

If violent scratching and rubbing be continued for a long 
period, the skin becomes more or less inflamed, varying in degree 
in different individuals, generally resulting in considerable infil- 
tration, thickening, and pigmentation. This state of the integu- 
ment may be frequently observed in those who have suffered for 
a long time with pediculosis. Excoriations play an important 
role in many diseases of the skin, and should always receive at- 
tentive consideration. Their number, form, distribution, and local- 
ization are in themselves sufficient in certain diseases to establish 
the diagnosis. 

FISSUKES. 

Syn.j Khagades ; Germ., Hautschrunden ; Fr., Fissures. 

Fissures are variously sized and shaped linear cracks 
or wounds, due to disease or to external agencies, having 
their seat in the epidermis or corium. 

They commonly occur about the well-marked normal furrows 
of the skin, as about the palms, soles, fingers, and toes ; they are 
also encountered in other regions. They assume various sizes, 
and appear as long, narrow or broad, superficial or deep, reddish, 
dry or moist, linear openings or clefts. They are either the result 
of a diseased condition of the tissues, as in eczema, psoriasis, or 
syphilis, or they may be caused by local irritants, as cold or 
chemical agents, acting injuriously upon the epidermis. Any 
portion of the surface which is liable to extreme tension may 
become the seat of fissures. They are generally painful, and in- 
terfere with tjie natural movements of the part. 



64 . , SYMPTOMATOLOGY. 



ULCERS. 
Syyi., Ulcera; Germ., Geschwiire; Fr., Ulceres. 

Ulcers of the skin are irregularly sized and shaped ex- 
cavations OF THE CUTANEOUS TISSUES, THE RESULT OF DISEASE. 

They vary extremely as to size and shape ; they may be no 
larger than a pin-head or as large as a hand, and even larger; 
in outline they are usually roundish, but they may also be irreg- 
ularly shaped, kidney-shaped, or serpiginous. Sometimes they ex- 
hibit an excavated or crater-like appearance ; in other cases they 
have a scooped-out form. They may be superficial, shallow, or 
deep ; not infrequently they extend into the subcutaneous struc- 
tures. They present a more or less moist, bleeding, or discharging 
surface, which may or may not be crusted. Their bases are 
smooth, uneven, or irregular; reddish in color; and are covered 
with a grayish, yellowish, or reddish, offensive or inoffensive se- 
cretion, which may be either abundant or scanty, according to the 
nature of the morbid process. Their edges are usually denned; 
not infrequently they are abrupt; at times they are markedly 
everted or undermined. Ulcers are the result of previous dis- 
ease, and occur in the course of a number of diseases, chief among 
which are syphilis, lupus, lepra, carcinoma, carbuncle, and furuncle. 
They may occur upon any part of the surface, but are most fre- 
quently met with upon the lower extremities. Their duration is 
variable ; they are seldom stationary, but show, on the contrary, 
a decided disposition to undergo change. Many tend to enlarge ; 
others manifest an inclination to heal. When repair takes place 
it is in the form of a cicatricial tissue, which remains permanently. 
Ulcers are usually painful. 

SCARS. 
Syn., Cicatrices ; Germ., Narben ; Fr., Cicatrices. 
Scars are new formations occupying the place of former 
normal tissue. 

They have a glistening, contracted appearance, and are sur- 
rounded by a normal skin, into which they imperceptibly blend. 
They are usually smooth and soft to the feel, and have a shining 
appearance; they may, however, be indurated or firm. They 
possess different forms or characters, according to the disease 



SYMPTOMATOLOGY. . 65 

which has occasioned them ; they may be on a level with the 
skin, or, as is more often the case, somewhat depressed ; they may 
also be raised. At times they are linear, band- or cord-like, and 
in other instances contracted, knotted, or puckered. Their color is 
usually whitish; but this varies, for if recent they may be pinkish 
or reddish, while if old they may be grayish, yellowish, or brownish. 
They consist of connective-tissue elements, and do not contain any 
of the normal structures of the skin, as hairs, glands, and papillae. 
Scars may be the result of disease or of injury. They are 
known to follow all of the ulcerative diseases, and also all injuries 
involving loss of substance, as burns, scalds, and wounds, also the 
application of caustics. Although they result from a variety of 
causes, many of them are found to be very similar in character ; 
hence they cannot be said to be positively indicative of the process 
which has occasioned them. At the same time they not infre- 
quently possess certain features — as, for example, outline, number, 
size, texture, and location — which point unmistakably to the origi- 
nal disease. They are generally permanent, continuing to exist 
through life with but little alteration ; occasionally they undergo 
more or less change. They are for the most part indolent ; in 
rare cases, however, they may be painful. 

GENERAL SYMPTOMS. 

All of the existing lesions present in a given case of disease, 
viewed as a whole, constitute what is known as an eruption. An 
aggregation of lesions, whether of the same or of different char- 
acter, go to make up what is termed a patch of disease. 

The individual lesions of a disease may all be of the same kind, 
as, for example, papules, in which event they are uniform ; or they 
may be different, of two or more kinds, macules, papules, and 
vesicles, for example, all being present, when they are said to 
be multiform. They may, moreover, be isolated, or discrete, or 
they may be so numerous as to be closely crowded, or confluent. 

The following expressions, descriptive of peculiar forms of le- 
sion, are used in connection with certain diseases, more especially 
in those cases in which the lesions are both uniform and numer- 
ous : when small, millet-seed sized, miliar is ; when pointed, acu- 
minatus; when of .the size and shape of a pea or bean, lenticular is, 
etc. Thus, common examples are found in the expressions miliary 

5 



66 SYMPTOMATOLOGY. 

papular syphiloderm, acuminated warts, and lenticular papular 
syphiloderm. 

The terms neonatorum, infantilis, adnttorum, senilis, etc., are fre- 
quently convenient to express concisely the time of life at which 
the disease occurs: for example, the sclerema of the new-born is 
called sclerema neonatorum; the eczema of infants, eczema in- 
fantile, etc. 

Distribution. — Great variation exists in the distribution of the 
lesions; they may occupy the whole or the greater part of the sur- 
face, or they may be localized to a small circumscribed area. They 
generally take the course of the natural lines of the skin, on the 
sides of the thorax, for example, running parallel with the ribs. 
Not infrequently they follow the course of nerve trunks, as in 
naevi, herpes zoster, ichthyosis hystrix, warts, and leprosy. They 
may further appear aggregated in patches, — aggregatus ; or they 
may be disseminated, — disseminatus. When an eruption involves 
the whole surface, it is said to be universal ; when various parts 
are affected, without regularity of distribution, it is called diffused. 

Configuration. — The lesions of the skin form themselves into a 
great variety of figures or patterns. Some of these are peculiar, 
and are characteristic and constant symptoms of certain diseases, 
while others are common to many diseases. In other affections 
they manifest themselves without attempt at configuration. The 
various outlines or forms assumed by individual lesions or by 
patches of disease are designated by the following suggestive 
terms. When the lesions occur discretely in the form of small, 
pin-head sized points, the condition is termed punctatus ; when 
they are of the size of drops, guttatus; if as large as pieces of 
coin, nummularis. As an example, certain of the forms of pso- 
riasis are known as punctata, guttata, and nummularis. 

When a patch, of whatsoever disease, presents a circular fornv 
it is called circincdus ; when in the form of a ring, annidatus, or 
annularis, as in tinea circinata. When the lesions appear in con- 
centric rings, the condition is expressed by the word iris, as, for 
example, herpes iris. Occasionally patches are encountered whose 
margins upon one side appear unusually sharp and well defined 
against the sound skin ; to these the name marginatus is given. 
The condition is often seen markedly developed in ringworm of 
the bod v. 



SYMPTOMATOLOGY. 67 

When the patches are circumscribed and are marked by an 
abrupt line of demarcation, as in psoriasis, for example, the 
word circumscriptus is used. If the patches arrange themselves 
in such a manner as to form winding or gyrate markings, the term 
gyratus is employed. This is sometimes observed in psoriasis. 
The designation serpiginosus is applied to those forms of disease, 
especially tubercles and ulcers, which pursue their course in a 
creeping, serpentine manner; as an instance, we speak of the ser- 
piginous tubercular syphiloderm. 

The state of an eruption, as to its striking feature, is often de- 
noted as follows: hypertrophicus, used in connection with hyper- 
trophies and new growths, is employed to indicate an exuberant or 
hypertrophic condition, as in lupus; exulcerans, when the process 
of ulceration is extensive, as often occurs in syphilis ; humidus or 
madidans, when moisture is present, as in eczema; and siccus, 
when there is absence of moisture, as in seborrhoea. 

Locality. — The regions of the body invaded vary with the 
disease. Certain affections are peculiar in that they attack only 
particular localities; some possess a decided preference for this or 
that region, while others exhibit no elective point of manifestation. 
Thus, lupus vulgaris and lupus erythematosus both tend to attack 
the face ; tinea favosa, the scalp ; acne, the face ; erythema multi- 
forme papulosum, the backs of the hands ; and erythema nodosum, 
the legs. In some affections, as psoriasis, the extensor surfaces of 
the extremities are almost exclusively involved ; while in others, 
as the erythematous syphiloderm, the flexor surfaces are the chief 
seat of disease. The form of the distribution of certain diseases 
is explained by peculiarities in the structure of the skin as found 
in various regions.* The terms capitis, facialis, brachialis, femo- 
ralis, abdominalis, palmaris, plantaris, etc., are conveniently used 
to denote the exact region involved ; as, for example, eczema 
capitis, herpes zoster facialis, etc. 

Symmetry. — Diseases of the skin may or may not be sym- 
metrical. The inflammatory diseases in particular, as eczema and 

* The localization of the various diseases of the skin has received attentive 
study from Oscar Simon, of Berlin, who established a scheme of architecture 
for the skin based upon the anatomical structure of this organ. See his work 
entitled " Die Localisation der Hautkrankheiten, histologisch und klinisch 
bearbeitet." Mit 5 Tafeln. Berlin, 1873. 



68 SYMPTOMATOLOGY. 

psoriasis, show a marked tendency to appear symmetrically upon 
either side of the body. The palms and soles, hands and arms, 
are often similarly affected at the same time. In some instances, 
as in erythema multiforme, symmetry is almost invariably present. 
It is generally seen to best advantage upon the extremities.* 

Color. — This necessarily varies with the nature of the patho- 
logical process. It also varies greatly according to the stage of 
the disorder, a point which must always be taken into considera- 
tion. In many diseases it is tolerably uniform and constant, as in 
psoriasis and in tinea versicolor. Different colors and shades are 
often seen in the several stages of a disease, as, for instance, in 
erythema nodosum. The tint is, moreover, often influenced by 
external agencies, as by heat or cold, and also by local treatment. 

When an affection is characterized by a prominent and uniform 
color, whether evanescent or permanent, it is at times designated 
by a term descriptive of this peculiarity ; iu this manner the ad- 
jectival words albidus, ruber, flavescens, melanodes, etc., are affixed 
to diseases, as, for example, eczema rubrum. 

SUBJECTIVE SYMPTOMS. , 

Diseases of the skin may or may not be accompanied by sub- 
jective symptoms. Among the inflammations, new growths, and 
neuroses they are of common occurrence; while among the hyper- 
trophies and atrophies they are either absent or are only occasion- 
ally encountered. They may be trivial, or, as is often the case, 
distressing in their severity and persistency. Disordered sensation 
occurs either in the form of a diminution of the normal sensibility, 
constituting ancesthesia, or as an augmentation of the same, termed 
hyperesthesia. The latter may be simple or perverted in charac- 
ter. More or less heat is present in all of the hypergemic and in- 
flammatory affections, notably in those running an acute course. 
Sensations described as burning, tingling, and smarting also not 
infrequently attend the same class of diseases. Itching, however, 
is by far the most prominent of the subjective symptoms, and is 



* For information on this question the reader is referred to Testut's valua- 
ble work " De la Symetrie dans les Affections de la Peau." Paris, 1877. For 
abstracts see Annales de Derm, et de Syph., t. viii. p. 385; also Archives of 
Dermatology, July, 1878. 



SYMPTOMATOLOGY. 69 

present in varying degree in a large number of disorders. It may 
be due to external causes, as, for example, parasites, or to internal 
causes, acting directly or reflexly, as in eczema and pruritus. It 
is variously described by patients. The sensation of formication 
— as though insects were crawling over the surface — may be men- 
tioned as one of the most striking varieties. Pain, of a burning 
or shooting, neuralgic character, is also sometimes experienced, as 
in herpes zoster, dermatalgia, and neuroma. 



ETIOLOGY. 

The causes at work in the production of the various diseases 
which affect the skin are manifold. In order thoroughly to com- 
prehend them it is of the utmost importance that an expansive 
view of the subject be taken, for in many instances it will be 
found that the manifestations upon the surface are but indexes or 
direct symptoms of disorder in other portions of the system. 

A large proportion of the cutaneous diseases are intimately asso- 
ciated with derangement of the internal economy, and are therefore, 
strictly speaking, symptomatic diseases. As striking examples of 
such complaints the polymorphous erythemata, the exanthemata, as 
well as certain pigmentary and hemorrhagic affections, may be cited. 

On the other hand, a great number of diseases have their origin 
in the skin itself, and are confined in their action to this organ 
alone ; these are the so-called idiopathic disorders. To this class 
belong all of the local diseases, as, for example, certain of the hy- 
pertrophies and atrophies, as well as those numerous conditions 
produced by external agencies, including parasites. It must never 
be lost sight of, however, that the relationship between the system 
at large and the skin is extremely close, so much so that very fre- 
quently it becomes a most difficult matter to determine to what 
extent a disease is local or constitutional. The line of demarcation 
cannot be a strict one. 

The subject of etiology may be considered under the three fol- 
lowing heads: conditions influencing disease; internal causes, or 
those which act from within the system ; and external causes, or 
those which act from without. 

CONDITIONS INFLUENCING DISEASE. 
Age.— It is well known that a number of diseases are liable to 
make their appearance at certain periods of life, while others may 

70 J 



ETIOLOGY. 71 

appear at any time. A limited number are noted to occur only at 
stated ages, thus manifesting a striking peculiarity. Thus, ichthy- 
osis first shows itself during early childhood, commonly at about 
the second year, occasionally earlier or at birth. The congenital 
syphilodermata appear, as a rule, between the first and third months 
of life; at times they are present at birth. Tinea tonsurans is a 
disease of childhood. Impetigo contagiosa is likewise almost ex- 
clusively confined in its origin to the early years of life. Tinea 
versicolor, on the other hand, is never seen in children. The vege- 
table parasitic diseases in general rarely occur in the old, but are 
met with from infancy to middle age; while pediculosis of the 
body is only exceptionally observed in the child. Carcinoma very 
rarely occurs in the young; it seldom manifests itself before middle 
age, and frequently not until old age. Pruritus in the majority 
of cases is an affection of adult life. 

Sex. — It will be found that some diseases are to a great extent 
peculiar to one or the other sex, while others are noted to be more 
common in one than in the other. For example, sycosis is met 
with only in the male; epithelioma is of more frequent occurrence 
in the male; while lupus, especially lupus erythematosus, is more 
common in the female. 

Seasons. — The seasons exert a marked influence upon many of 
the inflammatory affections, as well as upon those of other classes, 
as, for example, hypertrophies ; the majority of diseases are aggra- 
vated by cold weather, as is commonly observed in eczema, psori- 
asis, and ichthyosis. Pruritus hiemalis is encountered only during 
cold weather. Other disorders, again, occur only during the hot 
months, as, for instance, prickly heat; while still others incline to 
appear more commonly during the spring and autumn, as erythema 
multiforme. 

Climate. — The influence of climate in the production of cuta- 
neous disease cannot be questioned. Observations have established 
the fact that certain diseases are almost peculiar to certain coun- 
tries; as examples, leprosy, elephantiasis Arabum, frambcesia, and 
pellagra may be mentioned. To what extent, however, climate 
alone is to be held accountable cannot be definitely ascertained ; 
other agencies, as hygiene, diet, and the habits of the people, must 
also receive consideration as probably having a share in the causa- 
tion of the malady. 



72 ETIOLOGY, 



INTERNAL CAUSES. 



Here are to be classed all those causes originating internally, 
or of a constitutional nature, which arc known to be able in any 
way, however remote, to give rise to disease of the skin. They are 
numerous and call for profound investigation. At times they 
are very obscure and far removed in their seat from the skin; 
while, on the other hand, in some cases they are so commonplace 
as to be overlooked by the casual observer. 

Hereditability. — Some diseases are known to be hereditary ; as 
common examples, syphilis, leprosy, ichthyosis, psoriasis, and ec- 
zema may be cited. It must not, however, be supposed that these 
diseases are in every instance hereditary; for, according to my 
experience, the two latter affections are more frequently found to 
be developed in the individual de novo than to be transmitted from 
parents. Ichthyosis, likewise, often originates with the individual 
so affected. 

Predisposition. — By this term I mean a peculiar, inherent state 
of the constitution which inclines to the ready development of one 
or another disease. Its existence is not uncommon. The ten- 
dency may exhibit itself in one, or, as is often the case, in all of 
the members of a family. It may be inherited, or it may originate 
with the individual. Thus, it is a matter of every-day observa- 
tion that certain families manifest more or less of a disposition 
to the development, under favorable conditions, of some of the 
commoner forms of disease, especially those of an inflammatory 
character, as, for example, eczema. 

Constitutional Diseases. — These in many instances exert a po- 
tent influence upon the skin. At times the malady is of such a 
nature that its existence merely predisposes to disorder of the skin, 
as is the case, for example, in chlorosis; while in other instances, 
as in the exanthemata and in syphilis, it is of so violent a nature 
that the eruption is but one of a number of prominent and con- 
stant symptoms. In this connection it may be observed that gen- 
eral ill health, resulting from a variety of causes, plays a conspicuous 
part in both the causation and the continuance of cutaneous affec- 
tions; a recognition of this fact will frequently be of assistance as 
a guide in the treatment. It is owing to a deterioration of the 
normal state of health of the individual, for example, that furun- 



ETIOLOGY. 73 

culi, ecthyma, cachectic acne, and ill-conditioned excoriations often 
show themselves. Instances of this kind are frequently encoun- 
tered in large hospitals and in almshouses. 

Disorders of Internal Organs. — Here may be mentioned a 
number of functional and organic diseases capable, under peculiar 
conditions, of causing marked cutaneous manifestations. Thus, 
derangement of the alimentary canal is a prolific source of a large 
number of complaints, among which eczema, urticaria, and acne 
stand forth as prominent examples. Affections of the kidney, as 
Bright's disease, albuminuria, and diabetes, occasionally give rise 
to oedema, pruritus, and more rarely to eczema. Diseases of the 
liver are known to occasion discolorations, as in jaundice, also 
pruritus. Uterine diseases are likewise recognized as frequently 
causing pigmentary disturbances, urticaria, eczema, and other dis- 
eases. Finally, derangement of the nervous system is, as is now 
well recognized, capable of giving rise to a variety of disorders ; 
thus, eczema, herpes, urticaria, pruritus, and alopecia, also certain 
hypertrophies and atrophies, may be referred to as being not in- 
frequently caused and influenced by both functional and organic 
disease of the nervous system. 

Food. — Diet is doubtless accountable for a number of diseases. 
Improper quantity of food, whether too much or too little, and 
unsuitable quality, are both to be regarded as conspicuous factors 
in the causation of diseases of the most diverse nature. To keep 
the economy in a perfect 'state of equilibrium it is essential that 
the proper amount and kind of nutriment be taken into the sys- 
tem. Many skin diseases are without doubt due to improper diet, 
viewing the subject in its broadest sense; and in proof of this, 
one has but to glance at the clinics of our hospitals and dispen- 
saries, and to note the poor general health and inquire into the 
usual diet of the subjects of these disorders. Certain kinds of 
food are particularly liable to occasion cutaneous disturbance; 
fish, especially shell-fish, for example, is in many individuals 
sufficient to call forth urticaria. Some fruits, as strawberries, are 
in like manner at times followed by the same disease. Oatmeal 
and buckwheat are also known to occasion pruritus in some indi- 
viduals. The injurious effects of wine and beer, and of indiges- 
tible articles of food, as cheese, pickles, spices, pastry, and the like, 
are frequently seen in eczema, urticaria, acne, and other diseases. 



74 ETIOLOGY. 

The cause here is an exciting one, and, while indirect as regards 
the skin, is not on this account any the less positive in its results. 
Great latitude is to be granted in the consideration of this subject, 
for what proves poison to one is food for another. 

Medicine. — The ingestion of certain drugs used as medicines 
is at times productive of mischief upon the skin ; striking in- 
stances are observed in the urticarial eruption occasionally follow- 
ing the administration of copaiba and of cubebs. Quinine, chloral, 
belladonna, and morphia are also capable of giving rise to one 
or another form of efflorescence. The bromide and iodide of 
potassium are also known to produce peculiar and often severe 
forms of eruption. 

Pregnancy. — This state is not infrequently noted to exert a 
decided influence upon the skin. Now and then it is observed to 
occasion attacks of eczema, herpes, and pruritus, which disappear 
immediately upon the removal of the cause. Chloasma is like- 
wise frequently observed as an accompaniment of pregnancy. On 
the other hand, chronic affections, as eczema and psoriasis, are 
often observed to be much better during this period. The period 
of lactation is also noted to influence the course of some diseases, 
as eczema, psoriasis, and disorders of the sebaceous glands. Some 
women with chronic diseases of this kind are invariably better 
than usual, or even free, during this time, while others are in- 
variably worse. 

Dentition. — This process must be regarded merely as an exciting 
cause of cutaneous disorder; its importance, viewed in the light 
of a cause of disease, is secondary, and should not be over-esti- 
mated. Both eczema and urticaria are sometimes aggravated by 
this cause. 

Vaccination. — In addition to the usual local disturbance which 
this process occasions, it is now and then followed by peculiar 
erythematous, pustular, or furuncular affections; they occur, how- 
ever, comparatively rarely, and are usually benign in their nature. 
Occasionally, however, the disease is deep-seated, and is severe, 
giving rise to considerable inflammation of the skin and subcu- 
taneous tissues, variable as to form. 



ETIOLOGY. 75 

EXTEKNAL CAUSES. 

The causes of this nature are numerous. Many of them are to 
be viewed simply as exciting causes, giving rise to disorder only 
under peculiar conditions, or in those cases where there already 
exists a predisposition to the disease manifesting itself. Others, 
however, act injuriously upon the skin, and are the direct and 
only source of disease. 

Occupation. — Certain occupations are known to be productive 
of harm to the skin, giving rise to hyperemia, inflammation, or 
hypertrophy. Thus, workers in chemicals, as acids and alkalies, 
and in dye-stuffs, especially aniline products, and arsenic, are liable 
to suffer from the irritating substances with which they come in 
contact. Washerwomen exposed to the long-continued influence 
of water and strong soap, and masons, may also be referred to ; 
individuals following these occupations not infrequently have 
rough or harsh skins and fissures. Machinists, carpenters, shoe- 
makers, and others who make constant use of tools, are ordinarily 
the subjects of more or less epithelial hypertrophy upon the hands, 
in the form of callosities. 

The extremes of heat and cold also act as causes in the produc- 
tion of disease; as examples of the former, erythema and dermatitis 
resulting from continued exposure to a high temperature may be 
mentioned. As an instance, miliaria may be cited. The action 
of the sun in calling forth several varieties of disease, as simple 
dermatitis, and pigmentation, is w r ell known. Cold acts in a 
similar manner, as observed in frost-bite. 

Clothing. — Certain kinds of clothing, as well as unsuited modes 
of dress, must also be regarded as giving rise to irritation and 
hyperaemia of the skin. The rough flannel worn so persistently 
by the working classes not infrequently serves as an exciting cause 
of erythema or of follicular inflammation. Constant friction pro- 
duced by ill-fitting articles of wear over tender portions of the 
body, as a stocking or shoe over the instep or about the heel, will 
often suffice to give rise to excoriations, ulcers, and other forms of 
disease. 

Irritants. — Cutaneous irritants are the source of much mischief; 
for example, strong external remedies too freely used may prove 
causes of hyperemia and inflammation. Among these, as most 



76 ETIOLOGY. 

frequently occasioning disorder, sulphur, croton oil, the prepara- 
tions of mercury, caustics in general, rubefacients, and tincture of 
arnica may be mentioned. 

TJncleanliness. — Uncleanliness, or the presence of effete or for- 
eign matter upon the surface, must likewise be considered as an 
exciting cause of disease, though in my opinion it is of much less 
importance than is generally supposed. On the other hand, too 
much attention to cleanliness may also be followed by an ab- 
normal condition of the skin; the injudicious use of the bath and 
the constant use of strong soaps are hurtful to the welfare of the 
integument. The frequency of the bath should be regulated by 
the condition of the skin, especially as to secretion. 

Scratching. — This operation brings about material and often 
extensive lesions upon the surface, especially in affections of an 
inflammatory and pruriginous character. It is noted, however, to 
produce serious lesions only in those cases in which the skin has 
already become more or less altered by disease. Thus, while in 
scabies, pediculosis, eczema, and ecthyma scratching often creates a 
vast amount of local disturbance, greatly complicating the primary 
disease, it cannot be regarded as fruitful of the same amount of 
harm upon perfectly sound skin. In the disorders referred to it 
is, when protracted, the cause of structural changes in the skin, as 
manifested by excoriations, pigment alterations, and thickening. 

Contagion. — Among the external causes the most important 
remains to be spoken of under this head. The varieties of con- 
tagion are not numerous, but they are exceedingly prolific sources 
of disease. Among the infectious diseases, those which are com- 
municable through the medium of the atmosphere, smallpox, 
measles, scarlatina, and erysipelas, occupy the most conspicuous 
place; while the contagious affections, strictly speaking, those 
which are transmissible only through direct contact, comprise 
syphilis, contagious impetigo, vaccinia, certain low forms of specific 
inflammation, as equinia, and the parasites. Many of the cutaneous 
lesions of syphilis are contagious, and are active agents in the 
spread of this common malady. The disorders occasioned by the 
animal and vegetable parasites of the skin form a distinct group; 
they are all contagious, although not equally so, some being at all 
times readily communicable, while others manifest their contagious 
properties only under certain conditions. All individuals, for ex- 



ETIOLOGY. 77 

ample, do not seem to be to the same extent susceptible to their in- 
fluence; two persons may, under like circumstances, be exposed to 
the same parasite, only one of whom will, in all probability, con- 
tract the affection. Some persons, as attendants in hospitals and 
others brought into frequent contact with the contagion, rarely if 
ever contract these diseases. I am strongly of the opinion, there- 
fore, that with these parasites a peculiar condition of the skin is 
in most cases essential to the development of the disease.* The 
vegetable parasites (microscopic fungi) are termed the achorion 
Schonleinii, trychophyton, and microsporon furfur. To the group 
of animal parasites belong the itch mite, head louse, body louse, 
and crab louse, together with several other insects of less impor- 
tance, as the flea and bed-bug, which under favorable circumstances 
commit depredations upon the skin. 

. * Other opinions on this point are held hy excellent observers, among whom 
I may mention Dr. J. C. White, of Boston, whose views may he consulted in 
an article "On the Etiology of Skin Diseases," read before the American 
Dermatological Association. Boston Med. and Surg. Jour., Oct. 23, 1879. 



PATHOLOGY. 

The pathology of the skin is to be studied in the same light as 
that of other parts of the economy. The skin differs from other 
membranes only in its anatomy, which being complex is subject 
to a variety of alterations, some of which are peculiar to tin's 
organ. It is liable to the same pathological changes, as, for 
example, hyperemia, inflammation, hypertrophy, and atrophy, as 
take place in other organs, and consequently is to be regarded 
from the stand-point of general pathology. 

The morbid changes which occur in the skin are numerous, 
and are, moreover, liable to varied modifications. To compre- 
hend them correctly, a thorough knowledge of the normal struc- 
tures is absolutely essential. All portions of the integument, 
either separately or together, may be involved ; it is found, how- 
ever, that certain parts are more frequently invaded than others. 

The epidermis, partly in consequence of its serving as the ex- 
ternal covering of the body and therefore liable to a great variety 
of influences, and also because it is so intimately associated with 
the deeper and more important parts, is very frequently the seat 
of extensive disease. From its position it necessarily assumes a 
more or less prominent part in the pathology of all cutaneous 
manifestations. Even in those instances in which the pathologi- 
cal process is situated exclusively in the deeper structures, it is 
noted to show morbid changes, as desquamation and atrophy, the 
result of impaired nutrition in the deeper layers. It is a not un- 
common scat of hypertrophy, as seen in callosity and like affections. 
The vegetable parasites also have their habitat here, not infre- 
quently taking complete possession of its outer or horny layer. 
The delicate rete mucosum, owing to its close proximity to the 
corium, and the relations which it bears to this structure, is 
likewise a frequent seat of disease; it is involved in all of the 



PATHOLOGY. 79 

inflammatory affections, as eczema, herpes, and psoriasis, as well 
as to a greater or less extent in numerous other diseases. 

In the corium, however, occur by far the greater number of 
morbid processes. The peculiar structure of this tissue, consist- 
ing of a net-work of connective tissue, extensive plexuses of blood- 
vessels, lymphatics, nerves, and a complete system of glandular 
apparatus, renders it particularly liable to disorder. It is, more- 
over, through certain organs which have their seat in this tissue, 
for example, the sudoriparous glands, that numerous effete products 
of the economy find their exit, some of which give rise to cuta- 
neous disturbance. Hyperemias all have their seat in the corium ; 
likewise that great class of diseases, the exudations, or inflamma- 
tions. Hemorrhages also occur here, as in purpura. Hypertrophies, 
scleroderma, for example, atrophies, new growths of various kinds, 
all are seated mainly in the corium. Parasites, especially the itch 
mite and louse, also prey upon this tissue. It is likewise in the 
corium that certain structural changes of the bloodvessels, lym- 
phatics, and nerves take place, as found in angioma, lymphangioma, 
and neuroma. Functional disturbances of the nervous system, the 
so-called neuroses, likewise in part doubtless here manifest them- 
selves. 

Both the sebi parous and sudoriparous glandular systems are 
also attacked by functional disorders, as in seborrhoea and in 
hyperidrosis ; both may, moreover, be the seat of structural alter- 
ation, either alone, as in sebaceous cyst, or in connection with dis- 
ease of other tissues, as in lupus erythematosus. 

The hair and nail are also invaded by pathological processes, 
either idiopathically, as in tinea tonsurans, tinea favosa, and 
simple hypertrophy, or symptomatically, as in alopecia, eczema, 
and psoriasis. 

Hyperemia. — Cutaneous hyperemia consists in an excessive 
amount of blood in the capillaries of the skin. It is for the 
most part an ephemeral condition, lasting but a short time, after 
which the surplus blood returns to its accustomed channels, leaving 
the skin in its normal state. The seat of the disorder is in the 
superficial strata of the skin, either in the papillary or deeper 
layers of the corium. As a rule, it is not followed by desqua- 
mation, or pigmentation ; when these symptoms occur, it is a sign 
that some slight exudation has taken place. Instead of termi- 



80 



PATHOLOGY. 



Dating iu this manner, however, hyperemia may readily pass 
on into inflammation. Hyperemia may exist alone, running its 
course and ending as such, but inflammation cannot exist without 
having been preceded by hyperemia. It may arise from numer- 
ous causes, some of them quite different in kind, as, for example, 
heat, cold, and systemic disorder. 

The hyperemias possess certain characteristic features. Their 
existence is always marked by redness of the skin, varying in 
shade and tint from pink to dark red. The redness is superficial 
in character, and disappears altogether under pressure, but is ob- 
served to return instantly. The temperature of the skin is fre- 
quently elevated, and at times may even be felt with the hand to 
be markedly so. Hyperemias are ordinarily acute; they may last 
minutes, hours, or days. Slight tingling or burning seusatious, or 
merely a sensation of heat, occasionally accompany them. They 
give rise to a variety of external forms or markings upon the sur- 
face, which are usually irregular as to size, shape, and outline. 

Anaemia.— Directly the reverse of hyperemia is the condition 
termed anaemia, in which there is a deficiency in the amount of 
blood in the cutaneous capillaries. This state may result from an 
absolute want of blood in the general system in consequence of 
hemorrhage, or it may follow disease, as in chlorosis. It is char- 
acterized by loss of the natural color of the skin, succeeded by a 
blanched, whitish or yellowish hue, affecting, according to its cause 
and nature, either the whole surface or certain regions, as the ex- 
tremities. It is also attended by a decrease in the temperature of 
the surface, and at times by cold sweating. Anaemia does not give 
rise to substantive diseases of the skin, and therefore is of little 
importance to the dermatologist. 

Inflammation. — By this term is understood a pathological process 
characterized by changes in the circulation and bloodvessels, the 
exudation of liquor sanguinis and both white and red corpuscles, 
attended by the symptoms of redness, heat, swelling, and more or 
less pain. 

The changes which take place, with special reference to the 
skin, may be briefly summed up as follows. Hyperemia inva- 
riably precedes the process. After this condition has existed for 
a longer or shorter period, the first observable alteration in the 
tissues, as seen under the microscope, consists in dilatation of the 



PATHOLOGY. 81 

minute arterial vessels, followed by the same change in the venous 
circulation. It is found that during the commencement of the 
inflammatory process the blood flows through the vessels more 
rapidly than normal, while later this acceleration is followed by 
a marked retardation in the pace of the current, unaccompanied 
by contraction in thfe calibre of the vessels. The blood corpuscles 
now begin to accumulate in the vessels, which soon become filled, 
whereupon a condition of stasis occurs. At this stage the white 
corpuscles are observed to adhere to the sides of the vessels, and • 
to show increased activity of movement, whereby those adjacent 
to the walls gradually embed themselves in the coats of the artery 
or vein, and thus, working themselves through, find their way 
into the tissues without. The red corpuscles in the same way, 
though in less numbers, also pass through the walls of the ves- 
sels. The liquor sanguinis is in like manner freely exuded 
through the vessels in varying quantity. The process may be 
either acute or chronic in its course, its duration depending upon 
the nature of the cause and the continuance of the same in rela- 
tion to the affected part. It may terminate either in resorption, 
suppuration, or hypertrophy. 

The product of inflammation, that which results from .the ex- 
udation of the liquor sanguinis and the corpuscles, consists either 
of a fluid, of a semi-fluid, or of a formed cellular material ; not 
infrequently several of these products are at the same time pres- 
ent. Fluid exudation is composed of a serous, yellowish, gummy, 
albuminous liquid, containing usually a limited number of blood 
corpuscles, especially the white. The constituency of the exuda- 
tion, particularly as to the amount of cellular material, corpuscles, 
and cells, varies with the disease. Typical fluid exudation is 
observed in vesiculation, as, for example, in the vesicles of 
eczema and herpes; occurring in a less pronounced manner, it 
gives rise to swelling, oedema, and infiltration, which may be 
either circumscribed or diffused, as in multiform erythema and 
in erysipelas. 

Instead of a fluid the product of exudation may consist of 
formed elements, cells, unaccompanied to any extent by the escape 
of fluid, in which event it is firm or plastic, and may be either cir- 
cumscribed or diffused. Its presence in the skin is manifested by 
firm formations and infiltrations, examples of which are seen in 



82 PATHOLOGY. 

certain inflammatory papules and patches, as in eczema and psori- 
asis. In the process of pustulation, as in the pustule of ecthyma, 
is seen another form of exudation, characterized by the abundant 
presence of cellular material, pus corpuscles, suspended in simple 
fluid exudation. 

The lines of demarcation which separate the varieties of exuda- 
tion are by no means sharp; for, as seen clinically, all degrees of 
difference exist between the typical fluid, suppurative, and plastic 
varieties. Very commonly they pass from one to the other by 
gradual stages; or their course may be arrested at any stage of 
their existence. Thus, if certain of the exudative diseases, for 
example, erythema multiforme and eczema, be studied, many stages 
of exudation may often be observed, giving rise to the papule, 
papulo-vesicle, vesicle, vesico-pustule, and pustule. Viewed in 
this light, a number of cutaneous lesions result as the product 
of exudation, which either run a definite course or are subject to 
modification. 

The product of inflammation may have its chief seat in any of 
the various parts which compose the integument. Fluid exudation 
commonly seeks its outlet about the upper strata of the corium 
and between the papillary layer and the epidermis, or between the 
layers composing the epidermis, occasioning vesicles, blebs, and 
pustules; or, taking place in the deeper structures, it assumes the 
form of a serous infiltration, marked by cedema and swelling of 
the whole skin. Plastic exudation is usually found to have its 
seat in the corium and deeper layers, as seen in papules, tubercles, 
and similarly formed lesions. The product of exudation may 
disappear by the process of absorption, as occurs in urticaria and 
in many other diseases, or it may pass on in its course and end in 
suppuration, as, for example, in furuncle. 

Hemorrhage. — Cutaneous hemorrhage consists in the extrava- 
sation of blood from the vessels into the surrounding tissues, the 
result either of diapedesis, or the passage of the fluid through the 
walls of the vessels without rupture, or of rupture of the capilla- 
ries. It takes place in the skin in the same manner as in the 
other tissues of the body. The lesions consist of variously sized, 
more or less circumscribed, aggregations of blood, having their 
seat in the corium and subcutaneous tissues. They possess certain 
features bv which they may always be recognized. 



PATHOLOGY. 83 

They make their appearance suddenly. Having once assumed 
a definite size and form they usually retain it, until, by the grad- 
ual process of absorption, they fade and finally disappear. They 
always present a reddish color, varying in shade from light to 
dark, according to their nature, location, extent, and the length 
of time they have existed. In addition to the reddish color, they 
commonly exhibit, particularly about the period of their decline, 
more or less pronounced yellowish, bluish, and greenish hues. 
These variations are due to the changes which the coloring matter 
of the blood undergoes during absorption. The products of cuta- 
neous hemorrhage are peculiar in that they do not disappear under 
pressure. They are usually upon a level with the surrounding 
skin, though occasionally they become somewhat elevated in the 
form of papules or tumors ; this, however, rarely takes place ex- 
cept in extensive extravasations or in those cases in which the 
hemorrhage accompanies other lesions as a secondary symptom, 
as in hemorrhagic variola. They disappear slowly by absorption, 
leaving pigmentation of the skin. 

Hypertrophy. — By hypertrophy is meant an increase in the 
amount of a tissue which already exists. It may take place in two 
ways ; either by an increased growth of the already existing ele- 
ments, or by the formation of new elements of the same tissue. 
The component parts of the integument are all subject to hyper- 
trophy, the process either confining itself to one structure, as, for 
example, the epidermis, involving several or all of the parts at 
the same time. Typical hypertrophy of the epidermis occurs in 
callosities. In ichthyosis, corns, horns, and warts it involves both 
the epidermis and the papillary layer of the corium. Simple in- 
crease of the normal coloring matter of the skin is seen in lentigo 
and chloasma. Hypertrophy of the connective tissue is noted in 
scleroderma ; while in elephantiasis Arabum extensive augmenta- 
tion occurs in all the cutaneous and subcutaneous structures. The 
hair and nail are also subject to hypertrophy. 

Atrophy. — Here the process is exactly the reverse of hyper- 
trophy. It is characterized by a decrease in either the size or the 
number of the histological elements which make up the structure. 
"When the size alone of the elements is diminished, the condi- 
tion is termed simple atrophy ; when their number is lessened, it 
is called numerical atrophy. It may be either general, affecting 



84 PATHOLOGY. 

the whole surface, as in senile atrophy, or partial, involving a cer- 
tain region, as in atrophic macules and streaks, and in alopecia. 
All parts of the integument are liable to be attacked. In vitiligo, 
both marked atrophy and hypertrophy of the normal pigment of 
the skin go on together. Senile atrophy may be taken as the 
typical representation of general atrophy of the cutaneous struc- 
tures. The hair, as in canities or alopecia, in which diseases 
both the pigment and the structure of the hair are involved, 
may be cited as one of the most frequent seats of the process. 
The nail, at times, also suffers. 

Atrophy is usually characterized by diminution in size. It may 
either manifest itself as a simple reduction in size of the part af- 
fected, with structural change, or it may result in a degeneration, 
as in morphoea, in which event the tissues undergo change, a new 
structure different from the normal elements of the part coming 
into existence. Atrophy, succinctly stated, is want of balance be- 
tween the nutritive supply and the part to be nourished. 

New Growths. — New growths consist in the development of 
tissue which is new or foreign to the structure in which it 
occurs. Various forms of new growths, or new formations, as 
they are also termed, are met with, composed of tissue either sim- 
ilar to that of which the part is constituted, as, for example, con- 
nective tissue, or of a formation of an entirely different character, 
as cellular material. The connective-tissue new growths find their 
expression in keloid, fibrous molluscum, xanthoma, and scars. 
Cellular new formations, a most important pathological group, 
consist of deposits or infiltrations of cell elements foreign to the 
normal tissues ; here are found lupus vulgaris, lupus erythema- 
tosus, rhinoscleroma, lepra, carcinoma, syphilis, and other diseases. 
Bloodvessels and lymphatics are also the seat of new growths, as 
seen in angioma and lymphangioma. Clinically, new growths are 
either benign or malignant. 

Parasites. — Parasites of the skin are those organisms which 
prey upon the cutaneous tissues. They are divided into the 
vegetable and the animal. Vegetable parasites consist of minute, 
microscopic plants, which under certain conditions attach them- 
selves to the surface of the skin and there vegetate. They in- 
habit chiefly the horny layer of the epidermis, although they may 
penetrate even deeper, as into the follicles, and thus invade more 



PATHOLOGY. 85 

tender structures. The hair and nail are also attacked by these 
growths. 

Three varieties of fungus are known to invade the skin, each 
producing disease having distinctive clinical and pathological 
features. They are the achorion Schonleinii, the fungus of tinea 
favosa ; the trichophyton, giving rise to three affections, namely, 
tinea circinata, tinea tonsurans, and tinea sycosis ; and the micro- 
sporon furfur, the parasite of tinea versicolor. These three fungi 
are similar in structure, being made up of mycelium and spores. 
They all act as irritants to the skin. The amount of disturbance 
which their presence exercises varies with the parasite and the 
region attacked. They may be productive of hyperemia only, as 
sometimes occurs in tinea versicolor, or they may prove so irri- 
tating as to occasion extensive inflammation not only of the skin, 
but also of the subcutaneous connective tissue, as in tinea sycosis. 

The group of animal parasites comprise a number of insects, 
chief among which are the sarcoptes scabiei, or itch mite, and the 
pediculus, or louse. The demodex folliculorum, an exceedingly 
minute, inoffensive inhabitant of the sebaceous follicles, may also 
be here mentioned. Besides these there are others, as the leptus 
autumnalis; pulex irritans, or common flea; cimex lectularius, or 
common bed-bug; pulex penetrans, or sand-flea; filaria medinensis, 
or Guinea-worm; and certain varieties of flies. These insects, with 
the exception of the demodex folliculorum, all occasion various 
lesions upon the skin, which are either of an inflammatory or 
hemorrhagic nature. The ravages of the itch mite give rise to 
inflammatory lesions similar to those of papular, vesicular, and 
pustular eczema. The bites of the pediculus, flea, and bed-bug 
produce minute hemorrhages. 



DIAGNOSIS. 

If satisfactory results arc to be obtained in the treatment of 
cutaneous diseases, it is of the utmost importance that the phy- 
sician know definitely what affection he has before him. Without 
a full comprehension of the disorder, and of the course it is likely 
to pursue, all treatment must be empirical and attended only with 
hap-hazard results. With the assistance, however, of a method 
for the examination of cases, and of an understanding of the nu- 
merous signs and symptoms encountered, there should remain no 
greaf difficulty in the recognition of the diseases. One requisite, 
it may be stated, is indispensable to success in diagnosis, namely' 
the power of close observation and scrutiny, without which the 
student will acquire but a superficial and unsatisfactory knowledge 
of the subject. 

Light.— To examine a case properly the first point to be secured 
is suitable light. Daylight is an essential, for artificial light, as 
from a lamp or from gas, is necessarily more or less colored and 
gives to the skin an unnatural tint, by which it is easy to commit 
an error. A good white light is the best; under its influence we 
obtain a more correct idea of the color and shade of the eruption, 
always an important point, upon which alone may depend our 
decision. Various signs of value and interest frequentlv come to 
notice under a good light which might pass unperceived with an 
"'""'tain illumination; thus, a faint patch of tinea versicolor, or 
an early or fading erythematous syphiloderm, might readily escape 
detection with an imperfect light. 

Temperature of the Apartment.— A moderately warm room 
should be provided. The patient, whether in bed'or about, will 
of necessity be somewhat exposed to the air during the examina- 
tion ; sufficient warmth, therefore, is important both for his com- 
fort and to preserve the ordinary temperature of the skin. 

an 



DIAGNOSIS. 87 

Inspection. — The patient will generally direct onr attention to 
a certain part of the disease, usually that portion which causes 
him the most annoyance. And here, in the first examination of 
our patient, arises an opportunity for the exercise of tact. The 
portion offered to view should be slowly and attentively examined, 
and perhaps at the same time a few simple questions asked, with 
the purpose of gaining the confidence of our new patient. The 
physician should endeavor to obtain this as soon as possible. In 
women it must not be forgotten that a feeling of diffidence always 
exists when called upon to expose to a stranger even a portion of 
their person, and that to overcome this full confidence must be 
enjoyed. It may now be asked what other parts of the body are 
involved, and to what extent; and thus by carefully and judiciously 
placed questions it will be ascertained exactly what regions are 
affected. If the disease be diffused, the various parts should be 
inspected one by one. If the case be that of a man or child, it is 
desirable to examine the whole body, in order that nothing escape 
observation. This proceeding is the more important as the disease 
manifests a tendency to be scattered over the body, for, as will be 
shown presently, much is to be learned from the general features 
of the eruption. 

Examination to be thorough. — The examination during the first 
interview should be a complete and careful one, for it may happen 
that by the second visit the eruption will have undergone great 
change, and, indeed, have lost in a great measure its characteristic 
features. Cases should always be investigated at the time they 
first come under notice ; in order to know a disease well, it is es- 
sential to be familiar with all its phases, and hence every change 
in appearance should be recorded for reference. 

The general color of the skin should be noted, in order to de- 
termine its vascularity and its general vitality. It should be felt, 
in order to ascertain its temperature, whether increased or, dimin- 
ished. In rosacea of the nose, for example, the skin has the ap- 
pearance of being hot and inflamed, when touch sometimes actually 
reveals a sense of cold. Its softness or harshness, suppleness or 
rigidity, should also be ascertained. Certain diseases may be 
diagnosed by the sense of touch alone, as, for instance, ichthyo- 
sis, where its peculiar harshness is characteristic to an educated 
hand. It should be asked whether the patient is in the habit of 



88 



DIAGNOSIS. 



bathing, whether in warm or in cold water, and how often. Baths 
influence the skin, and especially an inflammatory eruption, in a 
marked manner. 

It should be noted, moreover, whether the body is fat or lean, 
and to what extent the cutaneous structures are nourished. The 
condition of the hair-follicles and sebaceous gland ducts should 
also be observed, whether open or plugged up; the epidermis, 
whether dry and desquamative or normal ; the secretion of sweat, 
whether scanty or profuse. In order to determine these points, the 
finger or hand may be passed over the surface, when their presence 
or absence will be readily recognized. 

Constitutional Disturbance.— In the majority of the diseases of 
the skin no perceptible constitutional disturbance exists, but there 
are, however, a certain number of instances where marked systemic 
derangement, as shown by fever, malaise, headache, constipation, 
and coated tongue, is always present at some time or other during 
the course. Symptoms of this character should be looked for, and 
carefully noted when present, for they sometimes prove valuable 
in enabling us to decide between affections which resemble one 
another in external form. The exanthemata, for instance, are 
always accompanied by symptoms of general disturbance, and in 
their early stages, at times, it is this alone which permits us to 
diagnose them from other diseases which they simulate upon the 
skin. Some of the syphilodermata are also accompanied by febrile 
symptoms. 

Age.— The age of the patient is to be taken into consideration ; 
whether an infant, a child, an adult, or an old person. We know 
that certain diseases occur almost exclusively at certain periods of 
life; that some affections are found only in adult life, and that 
Others are common only to infants. We know, moreover, that 
infants and young children are exempt from certain diseases; in 
questions of diagnosis, therefore, these can at once be excluded 
from the list. For example, psoriasis, one of the most frequent 
diseases in adult life, is not found in infants; Ave need not enter- 
tain its occurrence before the third or fourth year, and usually it 
does not show itself until the tenth or fifteenth year. Epithelioma 
seldom occurs in early life; it is seen now and then at the age of 
twenty or thirty, but is not common before forty or fifty. 

Sex.— The sex of the patient must likewise be taken into account. 



DIAGNOSIS. 89 

Males are more liable to certain affections than females, and vice 
versa. It is also to be borne in mind that, owing to peculiarities 
in the anatomy of one sex or the other, certain diseases are found 
in the one which have no existence in the other, as sycosis, a disease 
found only in the male. 

Temperament. — The temperament, or natural general organiza- 
tion of the patient, should be noticed; whether the complexion be 
light and florid or heavy and dark in color. It is well recog- 
nized that certain forms of disease are prone to come upon those 
whose constitutions are of a particular type. Diseases of the seba- 
ceous glands, for example, as acne and seborrhoea, are much more 
common upon those of the florid type. Eczema likewise occurs 
much oftener, and is more obstinate in character, in those of light 
oomplexion. 

Habits. — The usual habit of the patient must be inquired into, 
and his ordinary condition of health, apart from his cutaneous 
disease, ascertained. The state of the alimentary canal, a region 
so often the seat of derangement in certain inflammatory diseases 
of the _skin, must be most searchingly investigated ; not merely 
whether the patient suffers from dyspepsia or constipation, for 
questions of this kind are rarely sufficiently definite to elicit the 
true condition. Each part of the digestive tract should be gone 
over in turn with leading questions, assuming, for the most part, 
that some functional trouble does exist. Here in the alimentary 
canal we may find the key which will disclose the cause of many 
skin diseases of an erythematous or inflammatory type. Let the 
examination, then, in this direction be scrutinizingly conducted. 
Permit no point, however slight in character, to be passed over 
lightly, for upon it may depend the exciting cause of the disease. 

The tongue should be inspected, and its condition, if whitish, 
furred, thickened, moist, dry, or fissured, noted. At the same 
time, inquiry into the usual state of the breath should be made; 
whether heavy, offensive, or feverish ; if impure, the cause should 
be sought for; frequently it will be found associated with digestive 
or nervous disorders. 

Attention should next be directed to the stomach ; and here we 
must question our patient closely, asking him whether he is sub- 
ject to eructations, flatulence, acidity of stomach, or indigestion in 
any other form, or, if the case demand it, using the more popular 



90 



DIAGNOSIS. 



terras heart-barn and water-brash. Persons arc not infrequently 
encountered who positively deny all knowledge of any dyspepsia 
or indigestion, but who eagerly admit suffering from heart-burn. 
In this connection the quality and quantity of food taken may be 
inquired into, ascertaining whether the indigestion, for example, is 
due simply to certain articles of food or to other causes. Finally, 
the state of the bowels must be investigated, whether normal, 
temporarily or habitually constipated, or whether irregular in 
their action. In many cases it is of importance to make an ex- 
amination of the urine, a procedure which is always in place in 
the investigation of any extensive or serious disease. 

Occupation. — The occupation of the patient sometimes affords a 
clue to the cause of the disease. It is well known that various kinds 
of work play a part in the production and continuance of certain 
forms of disease. An affection, perhaps trivial in itself in character, 
may be greatly aggravated by exposure to irritating substances. 
For example, a very slight eczema upon a washerwoman's hand 
may be much increased by continued work, while ultimately a severe 
eczema rubrum of the whole arm may result. If she persist in 
her occupation*, the chances are that the affection will continue 
until she is compelled through sheer distress to desist. Workers 
in the manufacture of chemicals also suffer at times from artificial 
diseases; thus, those exposed in mercury and arsenic mines are 
subject to peculiar forms of eruption; while workers in caustics, 
acids, iodine, bromine, tar, and other similar substances, may like- 
wise be attacked with simple or peculiar disorders of the skin. 

GENERAL FEATURES OF THE DISEASE. 

We now come to consider the disease itself, including the lesions 
of the skin and their peculiarities. They must be attentively 
studied, for they afford the most accurate information which it is 
possible to obtain concerning the nature of the case; indeed, they 
offer the only knowledge which can be absolutely relied upon. 
One thoroughly familiar with the various cutaneous lesions is, as 
a rule, enabled to comprehend the whole character of a disease 
from simple inspection. 

Acute or Chronic. — It is, in the first place, to be noted whether 
the disease is acute or chronic in its course; and, furthermore, 
the stage in which it appears to be, whether upon the increase or 



DIAGNOSIS. 91 

upon the decline, is to be observed. In the majority of cases this 
can be learned by examination, or, when this is not possible, from 
the statement of the patient. It is also important at the same 
time to inquire into the duration of the complaint, and particularly 
whether it is a first attack or a relapse. 

Extent of Disease. — The extent of the affection may now be 
ascertained ; whether confined to a certain region or occurring in 
various portions of the body. The regions involved should be 
notedj for it is well known that some diseases have a predilection 
for certain parts of the body, as seen, for example, in seborrhoea, 
acne, and scabies. Other diseases are encountered only in definite 
localities, for example, sycosis. 

Distribution. — The distribution of the eruption may often serve 
as an aid in diagnosis. The configuration and shape of the patches, 
and the grouping and arrangement of the lesions, should all be 
observed. In some diseases, as, for instance, in herpes zoster, 
herpes iris, and the parasitic diseases, these are peculiar. 

Color. — The general color or tint of the disease will almost always 
throw considerable light upon the nature of the process, as, for in- 
stance, in many of the syphilitic eruptions, which possess a brown- 
ish-red, raw-ham, or coppery tint, particularly the case in the 
papular or tubercular formations. In xanthoma the color is dis- 
tinctly yellowish ; in keloid, pinkish or violaceous. In chloasma 
the pigmentation is of a pale or dark yellowish, more or less 
mottled, color. Tinea versicolor is likewise characterized by the 
same color, in addition to which the epidermis is the seat of 
furfuraceous desquamation. Tinea favosa also shows a yellowish 
coloration of the crusts. 

Individual Lesions. — It is to be noted whether the individual 
lesions are of one or of several varieties ; moreover, whether they 
are all in the same stage or in different stages of development. 
Their anatomical situation and number are also to be carefully 
inquired into. Finally, it is of the utmost importance to observe 
their evolution. 

Macules are of very frequent occurrence ; some remain as such 
throughout their entire course, as in chloasma, vitiligo, and tinea 
versicolor, while others, beginning as macules, gradually or rapidly 
pass into other lesions, as, for example, papules or tubercles, as seen 
sometimes in tinea sycosis. Hypersemic affections, as the simple 



92 



DIAGNOSIS. 



eiythemata, and discolorations of the skin from various causes, 
including pigmentation, all present examples of macules as their 
characteristic lesions. 

Papules occur either alone or in connection with other structural 
changes. In eczema the eruption may be altogether papular, or 
it may he a mixture of papules and vesicles in various stages of 
development, with scales, crusts, etc. In the small papular syph- 
iloderm, likewise, pustules are often seen intermingled with the 
papules. On the other hand, in lichen ruber, prurigo, lichen 
scrofulosum comedo, and milium, papules, possessing for the most 
part definite form, color, and structure, are observed. It will be 
remembered that papules are of several varieties, and that some 
of them arc quite unlike in their form and anatomy. 

Vesicles are common, and occur in a number of diseases. 
Vesicular eczema perhaps exhibits the lesion in its most perfect 
state; it is also observed highly developed in herpes, miliaria 
sudamen, vaccinia, and varicella. Vesico-pustules are seen in 
the so-called vesicular syphiloderm, in contagious impetio-o, and 
in other affections. 

Pustules are met with in variola, pustular eczema, ecthyma 
acne, scabies, the pustular syphiloderm, non-parasitic sycosis her- 
pes zoster, and in other diseases. Vesicles, as has been before 
stated, very frequently pass into pustules. 

The tubercle is often simply an exaggeration of the papule. It 
is seen in parasitic sycosis, acne, syphilis, carcinoma, leprosy 
rh.noscleroma, sarcoma, neuroma, etc. Tumors develop themselves 
in sebaceous cyst, epithelial molluscum, fibrous molluscum ery- 
thema nodosum, keloid, angioma, lymphangioma, lymphadenoma 
neuroma, lipoma, elephantiasis Arabum, syphilis, and in other 
diseases. 

Blebs, varying in size from a small cherry to a goose-eo-c are 
encountered chiefly in pemphigus and allied forms of eruption 
herpes ins, erysipelas, syphilis, and leprosy. They are also ob- 
served as the result of vesicants, scalds, and bums. 

Wheals are usually significant of a peculiarly sensitive state 
of the skin, which inclines to their ready formation upon slight 
provocation. They are seen most perfectly developed in urticaria ; 
they also sometimes occur, more or less pronounced in character, 
in connection with other diseases, as purpura. 



DIAGNOSIS. 93 

Scales are exceedingly common, and are observed in a variety 
of affections; psoriasis, seborrhoea, squamous eczema, ichythosis, 
erythematous lupus, and the vegetable parasitic diseases, all ex- 
hibit these products more or less typically. Scales form to a 
greater or less extent in all of the inflammatory diseases ; also in 
other classes of diseases, as, for example, in some of the hyper- 
trophies, as ichthyosis, and in certain atrophies depending on 
impaired nutrition. 

Excoriations are for the most part met with in those affections 
which are accompanied by itching and like symptoms ; they are 
seen chiefly in eczema and pruritus, and in pediculosis, scabies, and 
other parasitic affections. Fissures form in eczema, psoriasis, and 
syphilis ; also in various hypertrophies, as in ichthyosis, wart, and 
other forms of papillary growth. 

Crusts are found as the product of many diseases. They con- 
stitute striking lesions in eczema, scabies, ecthyma, syphilis, im- 
petigo, herpes, sycosis, leprosy, carcinoma, and scrofuloderma. 

Ulcers occur in syphilis, lupus vulgaris, carcinoma, leprosy, 
scrofuloderma, herpes zoster, furuncle, carbuncle, etc. Cicatrices, 
slight or extensive, always follow ulceration. They also follow 
certain new growths which are unaccompanied by ulceration, as 
lupus erythematosus. 



TREATMENT. 

It should always be the aim of the physician to cure the disease 
before him as rapidly and as effectually as possible; every known 
means calculated in any way to relieve the disorder should be 
brought to bear upon the case. No fears need be entertained of 
" curing the disease too soon/' or of "driving in the eruption," as 
this popular idea is variously expressed; the danger is rather in 
temporizing with the affection and thus permitting it to obtain the 
upper hand. It may be very safely stated that the sooner diseases 
of the skin are relieved the better both for the comfort of the 
sufferer and for the credit of the physician. Careful inquiry and 
extended experience show that no injurious results follow the cure 
of these diseases, whether this take place rapidly or slowly; in 
very many cases the time occupied in the treatment unfortunately 
extends over a long period, even under the most favorable circum- 
stances, so that speedy recovery, when it does occur, should always 
be regarded with favor. 

\h- who would be successful in the treatment of cutaneous 
affections must first acquire a full knowledge of the principles of 
genera] medicine; without this groundwork upon which to stand, 
his efforts, in the majority of cases, will at best be rewarded by 
unsatisfactory results. Dermatology, rightly viewed, is but a 
department of general medicine; its diseases, consequentlv, are 
amenable to the same principles of therapeusis which hold good 
for disorders of other organs. A simple acute inflammation of 
the skin, for example, calls for the same general plan of manage- 
ment as an acute inflammation having its seat in the mucous 
membrane or in other tissues of the body. The skin is but a part - 
of the whole organization, and subject, therefore, to general rules 
of treatment. 

94 



TREATMENT. 95 

Before prescribing for a case there are a number of points which 
should be taken into consideration, which may be referred to under 
the following heads. 

Previous History. — Not infrequently the previous history of the 
patient, and more particularly of the disease itself, will prove of 
assistance in determining upon the most suitable method of treat- 
ment. In the first place it is to be ascertained whether the present 
disease is a first attack or a relapse. If the latter, the course of 
the former attack, as well as the nature of the treatment, should 
be inquired into; whether external or internal remedies were em- 
ployed, and whether they proved, successful or otherwise. The 
preparations used should also, when practicable, be learned from 
the patient; for a knowledge of past treatment and its results may 
occasionally save both time and trouble. Idiosyncrasies, it must 
be borne in mind, are encountered from time to time ; hence, for 
example, when we are assured by a patient that arsenic taken 
internally or tar used externally invariably disagrees,' the infor- 
mation enables us to be cautious as to the manner of prescribing 
these remedies. 

Present General Condition. — The general condition of the pa- 
tient should be carefully ascertained. At a glance it is noted 
whether the patient is or is not in apparent good health ; whether, 
for example, there is a tendency to plethora or to anaemia, or to 
chlorosis. In this connection it is important to determine the 
presence or absence of constitutional symptoms ; whether the 
disease is strictly local or not. The appetite should be inquired 
after; likewise the state of the alimentary canal. The tongue 
should be examined, if normal or otherwise, and the existence or 
not of dyspepsia questioned. The state of the bowels requires 
special attention ; if natural, irregular, or constipated in their 
function. The character of the biliary and renal secretions also 
calls for investigation. The condition of the nervous system, 
moreover, should be determined; the amount and kind of sleep 
enjoyed, the state of the mind, whether healthful or morbid, de- 
pression of spirits, or other like symptoms, should all be noted. 

Nature of the Disease. — Directing attention now to the skin 
itself, it is all-important to form a definite idea as to the nature 
of the process present ; whether, for example, it is a simple hy- 
persemia, an inflammation, an hypertrophy, or a combination of 



9G TEEATMENT. 

processes. Recognizing the pathological process, less difficulty 
is experienced for the diagnosis. 

The duration of the disease should be in like manner ascer- 
tained ; its natural course studied ; whether localized to a small 
area or diffused, and its tendency to confine itself or to spread. 
It is important, also, to determine before prescribing whether it 
is acute, subacute, or chronic, and, still further, to recognize the 
precise stage of the process. The subjective symptoms, moreover, 
should be learned from the patient ; whether pain, burning, or 
itching is experienced, and, if present, the degree of the symptom. 

Cause of the Disease. — The importance of forming a correct 
opinion as to the cause which has given rise to the affection is so 
apparent as scarcely to call for more than mention. Upon a 
proper interpretation of this point will depend the success or the 
failure of treatment, It is only by treating the cause in many 
cases that permanent relief may be looked for. Too much study 
and investigation can scarcely be devoted to a comprehension of 
the case as a whole; let it be remembered that each case demands 
special study and a plan of treatment adapted to its needs. The 
lesions themselves, as a rule, except in the case of local diseases, 
call for but secondary treatment; they are of little consequence 
when compared to the cause which is continually producing new 
lesions. When, however, as too frequently occurs, no cause for 
the disease is to be detected, the lesions themselves should be 
vigorously attacked by every means at hand, with a view of re- 
moving them as soon as possible. In those instances in which the 
affection is known to be altogether local in its origin, nothing 
further than the treatment of the lesions is called for. 

Method of Treatment. — For the relief of diseases of the skin, 
speaking in general terms, both constitutional and local remedies 
are demanded. They may be prescribed conjointly or alone, ac- 
cording to the nature of the disorder. Experience proves con- 
clusively that in many cases constitutional or internal treatment is 
by far the most effective, while in other instances local measures 
offer not only the best, but at times the only, means of relief: 
such being the case, I think, therefore, it is plain that neither 
method employed to the exclusion of the other is capable of 
yielding the best results which it is possible to obtain. Where, 
however, external means are sufficient to relieve the trouble both 



TREATMENT. 97 

promptly and permanently, internal treatment is not only super- 
fluous, but may be productive of harm. 

Viewing the subject as a whole, I am strongly of the opinion 
that the most satisfactory results are to be obtained from the con- 
joint employment of both plans of treatment. The affections, 
and more particularly the individual cases, in which either local 
or constitutional remedies are to be prescribed, can be determined 
only by taking into account both the nature and the cause of the 
complaint under consideration. No positive rules can be given 
for the use of either one or the other class of remedies, for it will 
be found that the skin in a state of disorder is a sensitive organ, 
subject to no fixed laws of behavior. The remedy suitable for 
one stage is frequently not only powerless but often absolutely 
injurious in another stage of the same disease. 

CONSTITUTIONAL TKEATMENT. 

Under this heading may be considered the following: 

Hygiene. — In this connection may be mentioned the benefits to 
be derived from attention to the ordinary rules of hygiene. In 
not a few disorders, especially those of a chronic nature, much is 
to be gained from regulated and judicious exercise, more particu- 
larly out-door exercise suited to the demands of the patient, taken 
in sunshine. The advantages resulting from this adjuvant in 
therapeusis are most strikingly seen in cases in which there are 
marked elements of chlorosis or of disturbance of the nervous 
system. The effect of change of climate upon certain diseases 
is at times followed by the most salutary results. In certain re- 
bellious cases of urticaria, psoriasis, furunculus, and eczema, the 
change may be followed by decided, and at times prompt, relief; 
also, in leprosy and allied diseases. 

Food. — For the permanent relief of certain disorders the use 
of a regulated diet is most important. The kind and quality of 
the food consumed are both considerations of consequence in the 
treatment of a number of diseases. The diet should always be 
directed by the physician, and should consist of those articles 
which are suggested as being proper for the case under care. 
Beneficial results may also sometimes be obtained from a complete 
change of diet, as in eczema and psoriasis. 

Cod-liver Oil. — This remedy is an exceedingly valuable one. 
7 



98 



TREATMENT. 



It is especially useful in all those cases in which the general health 
has become impaired through the long-continued consumption of 
improper and insufficient food, bad hygienic surroundings, and 
like causes. It is prescribed to greatest advantage in scrofulo- 
derma, affections of the sebaceous glands, lupus, and eczema. In 
certain cases of eczema occurring in strumous children it is of 
particular value; also in some cases of relapsing ringworm. The 
dose should always be liberal, varying from a fluidrachm to a 
half- ounce or more, according to the age of the patient and the 
tolerance of the stomach. 

Iron.— The preparations of iron must also receive mention as 
being useful in the treatment of skin diseases. Their adminis- 
tration, alone or in combination with other remedies, is indicated 
in a number of affections. They are given with benefit in diseases 
dependent upon chlorosis, and also in inflammatory diseases ac- 
companied by general impoverishment, as in some forms of acne, 
eczema, and psoriasis. Other disorders may also be benefited by 
its judicious use. The wine of iron may here be referred to as a 
desirable preparation, suitable for many conditions where a mild 
tonic is required. It constitutes an excellent vehicle for the 
administration of both arsenic and iodide of potassium. 

Quinine. — This may be given with advantage in many diseases, 
as, for example, in certain of the erythematous inflammations, as 
erysipelas, and in elephantiasis Arabum. It is found, however, 
to be of particular value in the neuroses, as in pruritus, also in 
urticaria, and in other diseases complicated by nervous disturbance; 
also in diseases accompanied by a malarial element. It is some- 
times valuable in furuncle. 

Arsenic. — As is well known, arsenic has long been held in high 
esteem as a remedy in cutaneous medicine. At the present day 
there exists a great diversity of opinion concerning its worth as a 
therapeutic agent against this class of diseases, certain dermatolo- 
gists claiming to derive positive good from its employment in a 
number of affections, while others of equal experience are inclined 
to place but little reliance upon its curative powers. Without 
hesitation I would express myself of the opinion that it is a remedy 
of very great value ; that it is, in fact, the most valuable of ail 
internal remedies in the treatment of many skin diseases ; but the 
cases in which it is prescribed must be selected if successful results 



TREATMENT. 99 

are to be looked for. To say that arsenic is of use in " diseases of 
the skin," viewed collectively, is to make an assertion so vague 
and meaningless as to be of no practical value. Not only is it 
necessary to specify the disease, but also the stage of the affection, 
if we would employ it successfully. 

Arsenic exerts its influence chiefly upon the mucous layer of the 
epidermis. Hence it is found that diseases involving the more 
superficial parts of the skin are most benefited by its administra- 
tion. It possesses but little power over the affections which have 
their seat in the, deeper structures. Its action upon the skin is 
often slow, weeks and months sometimes being requisite to pro- 
duce the desired result ; improvement once obtained, it is gener- 
ally expedient to allow the patient to continue its use for some 
weeks after all symptoms of disease have disappeared, perhaps in 
smaller doses. It should not be given in the acute, inflammatory 
stage of any disease of the skin ; it should never be prescribed 
when there is great heat, burning, intense itching, or rapid cell 
change. It is not only of no good at this time, but is often pos- 
itively injurious, tending to augment the activity of the morbid 
process. It stimulates the rete, when rest is demanded. Its ad- 
ministration, then, in whatsoever disease, should be withheld until 
the acute symptoms have completely subsided. 

It is unquestionably of great value in psoriasis ; but it is not of 
benefit in every case, nor should it be directed in all stages of this 
disease. Where the process is very active, and attended with in- 
tense hyperemia, it as a rule only increases the already inflamma- 
tory condition. The more active the cell proliferation the less 
probability is there of its being beneficial. On the other hand, 
the more indolent and sluggish the process the greater the chance 
for improvement. It may be stated, as a rule, that it should be 
withheld until the disease has settled in its course. 

It is of decided service in certain varieties of eczema, especially 
in the papular and squamous forms ; also, I think, in those cases 
where the true primary lesions are ill defined, and where there is 
but slight infiltration of the skin. Certain persistent localized 
papular and abortive vesicular eczemas, as frequently seen, for ex- 
ample, about the fingers, also often readily yield to it. Chronic 
infantile eczemas, unaccompanied by digestive disturbance, are 
at times most favorably influenced by the remedy. As is well 



100 



TREATMENT. 



known, children stand relatively large doses. Viewing the subject 
in a broad light, however, I may state that too much should not 
be expected of arsenic in eczema. Many cases are in no degree 
improved by its use ; some, on the contrary, are aggravated. 

Pemphigus is often permanently relieved by its judicious use. 
Experience has shown it to be of great value in many cases of 
this disease. Discrimination must be made, however, between 
true pemphigus and pemphigoid eruptions. In the later stages 
of lichen ruber it is also prescribed with the greatest advantage. 
In certain forms of acne, especially in those cases where the lesions 
are numerous and of a fine papular character, its administration is 
frequently followed by good results. 

The preparations which it is advisable to employ are arsenious 
acid, liquor arsenici chloridi, and liquor potassii arsenitis (Fow- 
ler's solution). The latter will be found the most desirable form 
for ordinary use. Arsenious acid is given in pill form, usually 
combined with sugar of milk or with black pepper and powdered 
liquorice, the latter combination constituting the so-called " Asiatic 
pill," which may be prescribed in varying strength, suitable to the 
case. The following is the formula somewhat modified : Arseni- 
ous acid, two grains; black pepper and liquorice powder, of each 
thirty-two grains, with a sufficient quantity of mucilage; mix and 
divide into thirty-two pills. S.— One to be taken three times a 
day, directly after meals. The strength of the pill may be altered 
to suit the case. 

^ The liquor potassii arsenitis is best given combined with a bitter 
tincture, or with the wine of iron, or with an elixir of calisaya 
bark. Prescribed in this way there is less likelihood of gastric 
and intestinal derangement. The mode of ordering the solution 
pure, and directing so many drops to be taken at each dose, is, I 
think, objectionable for many reasons, to which it is unnecessary 
to refer. The average dose which will be found to be suitable to 
the majority of individuals is three minims. Four or six minims, 
and even much larger doses, will often be tolerated ; out of a 
number of patients, however, comparatively few will be able to 
take more than three or four minims for any length of time with- 
out derangement of the system. The solution of the chloride of 
arsenic is prescribed in about the same dose as Fowler's solution. 
Arsenic should always be given either with the food or directly 



TREATMENT. 101 

afterwards. Its toxic effects should be watched for and guarded 
against. Occasionally they appear insidiously. Idiosyncrasies 
are also liable to be met with.* 

Phosphorus. — The diseases in which this substance may be pre- 
scribed are those in which iron and arsenic are indicated. It is 
not, however, well tolerated by the stomach, and it is partly on 
this account, probably, that the views of observers as to its efficacy 
are conflicting. It has been used with success in psoriasis and 
eczema, and in lupus and other diseases. It is best administered 
in the form of a phosphorated oil enclosed iu capsules, the dose 
being about one-fiftieth of a grain of the phosphorus; also in the 
form of phosphide of zinc. 

Tar, Carbolic Acid. — Both of these substances are at times em- 
ployed internally with good result, as in psoriasis, eczema, and 
pruritus. Tar should be ordered in capsules ; carbolic acid may 
be given in pills. 

Mercury. — The preparations of this metal are sometimes used 
for disorders of the skin other than those of a syphilitic nature. 
Thus, minute tonic doses of corrosive sublimate, alone or with 
bark, are often taken with benefit in certain chronic inflammatory 
diseases accompanied with thickening, as, for example, eczema. 
In syphilitic diseases they are of course invaluable. The corrosive 
chloride, protiodide, bin iodide, mercurial pill, and gray powder are 
the forms in which it is commonly prescribed. The effect of 
the mercurials upon the system should always be noted with the 
greatest care, and in no case should they be given until ptyalism 
has been produced. Mercury is also combined most advantageously 
with iodide of potassium. Here may be mentioned Donovan's 
solution (liquor arsenici et hydrargyri iodidi), a remedy of some 
repute in the treatment of syphilitic manifestations. 

Iodide of Potassium. — This finds its chief use in scrofuloderma, 
lupus erythematosus, lupus vulgaris, and the syphilodermata. In 
the last named class of affections it may be administered either 
alone or in combination with mercury. It is prescribed in doses 
varying from two to fifteen or twenty grains, largely diluted with 



* The value of arsenic in skin diseases has heen ahly considered by Bulkley, 
in a monograph entitled " The Use and Value of Arsenic in the Treatment 
of Diseases of the Skin." New York, 1876. 



102 TREATMENT. 

water. "When used in non-syphilitic diseases the dose should be 
small. It must be remembered that the remedy itself is capable 
of producing varied forms of eruption. 

Aperients. — This class of remedies is of great service in many 
of the inflammatory diseases. Saline laxatives, as the sulphates 
of magnesium and sodium, cream of tartar, and Rochelle salt, are 
to be specially recommended, and may be given with marked benefit 
in the early stages of the majority of the acute inflammatory dis- 
eases. They should, however, be used with discretion, and never 
to the extent of violent purgation. They are also found to be useful 
when prescribed with other substances, as, for example, iron, acids, 
and barks, in the form of a draught. 

Mineral Spring- Waters. — These, especially those possessing 
Cathartic and alterative properties, are at times taken with benefit. 
Among those which have proved of value in my experience are 
the various sulphur waters, as those of Virginia, Kentucky, and 
New York. The alkaline waters, as the Carlsbad and Vichy 
springs, are also frequently beneficial in certain cases of eczema 
and psoriasis. 

Diuretics. — Remedies exerting an eliminating influence upon 
the kidneys are administered with advantage in highly inflamma- 
tory diseases complicated with defective excretion, as, for example, 
in some cases of eczema and psoriasis. Saline, non-stimulating 
preparations are preferable, the citrate, acetate, and bicarbonate of 
potassium, in twenty or thirty grain doses, being those from which 
the most relief is usually to be derived. Taraxacum may also be 
mentioned. The alkalies are found to be of particular value in 
cases dependent upon or complicated with gout or rheumatism. 
The condition of the urine should receive due attention, especially 
in certain of the acute inflammatory diseases, as urticaria, and in 
pruritus. 

LOCAL TREATMENT. 

External remedies are used with the view either of temporarily 
relieving or of curing the condition. They are numerous, and 
include a great variety of substances, which are employed either 
alone or more often in combination. They may be conveniently 
considered under the following heads. 

Baths. — Water, used for the purpose of cleansing the skin and 



TREATMENT. 103 

removing from the surface effete matter, as scales and crusts, or in 
the form of baths, simple or medicated, is an essential therapeutic 
agent. Its employment should, however, always be directed with 
judgment, inasmuch as in certain morbid conditions it is liable to 
produce more mischief than good. Where plain water is required, 
care should be taken to procure soft or rain water; many waters 
are hard and irritating to sensitive skins. The simple warm bath 
is especially serviceable in inflammatory diseases, as psoriasis, 
and in hypertrophies of the epidermis and coriura, for example, 
ichthyosis. 

Medicated baths are prepared with various substances. Starch, 
bran, gelatine, and the like, are added to the plain bath for the 
purpose of obtaining a bland, unirritating water, which finds its 
chief use in highly inflammatory conditions. Tar and sulphur, as 
well as other remedies, are also prescribed in the form of baths. 
Alkaline baths, made with the carbonates of sodium and potassium, 
or borax, are of decided value i,n the neuroses and in parasitic dis- 
eases; also in the acute and in the desquamative stages of some of 
the inflammatory affections, as psoriasis. Cold, douche, vapor, and 
hot-air baths are likewise often useful. The continuous bath, so 
constructed that a patient is enabled to remain continuously in the 
water for days or weeks at a time, is valuable in the treatment of 
extensive chronic inflammations, as psoriasis and pemphigus, and 
in burns. 

Soaps. — Two varieties of soap are made use of, the soda or hard, 
and the potash or soft. Both are important therapeutic agents, 
and are brought into frequent requisition for various purposes. 
Castile soap, the representative of the hard soaps, finds its office 
mainly in cleansing the skin of simple extraneous matter. It is a 
neutral soap, is bland in its action, and may be advantageously 
employed in many diseases preparatory to the application of other 
remedies. 

Soft soap, termed also sapo mollis and sapo viridis, is a soft, 
brownish or greenish soap, containing an excess, in varying 
amounts, of caustic potash. The fatty substance from which it is 
made may be either animal fat or vegetable oil ; it may further 
be either pure or impure in quality, points of difference in the 
manufacture which account for its variable characters as to con- 
sistence, color, odor, etc. It is an indispensable remedy in the 



104 TREATMENT. 

hands of the dermatologist ; it may be used alone, with water, 
with alcohol in the form of a tincture, or in combination with 
oils and other substances. It is an invaluable detersive agent, 
and is usually sufficiently strong to free the skin of scales, crusts, 
and other foreign matter. Its effect upon the skin is mildly 
caustic. AVhcn applied for any length of time or repeatedly, its 
caustic property should be counteracted by the subsequent appli- 
cation of some oily or fatty material, to prevent roughness, chap- 
ping, or Assuring, and contraction of the epidermis. 

Medicated soaps, as, for example, those containing tar, carbolic 
acid, thymol, and sulphur, are at times serviceable in the milder 
forms of disease; as a rule, however, better results are to be ob- 
tained from the same substances in other form. They may some- 
times be employed with benefit as adjuvants. 

Bandages. — Appliances of this kind are often made use of with 
advantage for the purpose of protection or of affording support 
to the skin and subcutaneous tissues. In eczema, elephantiasis 
Arabum of the extremities, and ulcers, for example, the plain 
roller or rubber bandage is employed with the greatest benefit. 1 

Poultices. — Preparations of this kind have but a limited use in 
dermatology. They are occasionally useful for removing large, 
adherent masses of crust, as in severe and long-standing eczema 
of a part. They are also employed to relieve pain and to hasten 
suppuration in furuncle, carbuncle, and like inflammations. They 
may be prepared with flaxseed meal, potato starch, or bread and 
milk, should always be applied as hot as the part will bear, and 
should be repeatedly renewed. 

Lusting Powders. — These play an important part in the manage- 
ment of certain of the hyperaemic and inflammatory disorders, as 
in erythema, intertrigo, and eczema. They are also employed in 
diseases of the sweat glands. They are composed either of one 
or of several substances, mixed in varying proportions. Wheat 
starch, corn starch, oxide of zinc, lycopodium, asbestos, oleate of 
zinc, boracic acid, alum, salicylic acid, French chalk, talc, orris 
root, and arrow root, reduced to fine, impalpable powders, are all 
used for this purpose. They should be prepared with care, and 
should be perfectly smooth and entirely free from grit. The 
blander substances serve to protect the surface from the influence 
of the air, from irritation and rubbing, and absorb exuded fluids. 



TREATMENT. 105 

lotions. — Lotions constitute a desirable and cleanly means of 
applying a number of remedies. In many instances they are 
better adapted for the relief of disease than ointments ; this is 
particularly the case when the affection occupies a large amount 
of surface, as, for example, in pruritus. They may be classified 
for convenience into those which are soothing, stimulating, and 
astringent. 

Soothing lotions are usually aqueous preparations containing 
certain substances which allay nerve irritation and give ease; 
those in common use are black wash, lead water, glycerine and 
water in various proportions, various glyceroles, as of lead and 
bismuth, weak solutions of carbolic acid, thymol, hydrocyanic acid, 
boracic acid, and the weaker alkalies. These find their use chiefly 
in the inflammatory affections, and most frequently in eczema. 

Stimulating lotions commonly contain alcohol, certain oils, aqua 
ammonia?, acetic acid, cantharides, carbolic acid, corrosive subli- 
mate, tar, alkalies, camphor, thymol, benzoic acid, chloral, sul- 
phur, sulphuret of lime, etc. ; often several of these substances are 
contained in the preparation. They prove of value in affections 
of the scalp, as in seborrhea, eczema, and psoriasis, where oils 
and ointments are contra-indicated on account of the hair. They 
are also of service in diseases of the glands, and in chronic in- 
flammations, as in acne, acne rosacea, and eczema. Astringent 
lotions are made with alcohol, tannic acid, alum, iron, vinegar, 
and like substances ; their principal employment is in hemorrhages 
and in excessive sweating. 

Oils. — Natural oils may be either bland or stimulating. To the 
former class belong olive oil, oil of sweet almond, linseed oil, 
castor oil, cod-liver oil, and the petroleum ointments. Here may 
also be mentioned glycerine, one of the most useful of external 
remedies. Bland oils are serviceable in softening scales and crusts, 
and for anointing the surface in a variety of conditions. They 
also enter largely into the composition of ointments and lotions. 
Examples of stimulating oils are found in the derivative oils from 
tar, as oil of cade and oil of birch, and in oils derived from certain 
nuts and balsams, as the oil of cashew-nut, gurjun balsam, etc. 

Ointments. — Ointments constitute the usual and by far the most 
valuable means of applying remedies to the skin. They are made 
with various fats, commonly with lard, and contain one or more 



106 TREATMENT. 

substances upon which their chief virtue depends. Like the lotions 
and the oils, they may be divided into those which have a soothing 
effect and those which stimulate. 

Sedative Ointments. — In this class may be placed simple oint- 
ments and cerates, glycerine ointments, ointments of cacao butter 
and spermaceti, cucumber ointment, petroleum ointments, diach- 
ylon and oxide of zinc ointments, and other preparations pos- 
sessing similar properties. They are bland in their nature, and 
are employee! chiefly in inflammatory conditions, with the view of 
protecting the surface and of allaying irritation. Diachylon oint- 
ment, prepared either from diachylon plaster or from litharge with 
olive oil, is a useful remedy in the treatment of a number of con- 
ditions. Oxide of zinc, oleate of zinc, and oleate of bismuth 
ointments are likewise valuable preparations, finding their prin- 
cipal uses in eczema. These ointments are frequently made to 
serve as vehicles for the application of other remedies. 

Stimulating Ointments. — These are the most efficacious of rem- 
edies. They are made with a great variety of substances, which 
are employed either alone or in combination. Tar and its de- 
rivatives, for instance, oil of cade and oil of birch, may first be 
mentioned ; they are especially valuable in eczema and psoriasis. 
Carbolic acid occupies a position scarcely less important than tar, 
being one of our most useful remedies. Thymol is also valuable. 
The preparations of mercury, including the red oxide, nitrate, red 
iodide, mild chloride, corrosive chloride, ammoniated mercury, 
and mercury itself, are all employed, and are highly prized for 
their virtues in numerous and different diseases. Sulphur, and 
its many combinations, as the sulphides and sulphites, may also 
be referred to as among the more important remedies of this class. 
Here may be mentioned goa-powder and its derivative chryso- 
phanic acid (chrysarobin) ; also pyrogal lie acid. Camphor and 
chloral are also occasionally used. Stimulating ointments are 
made in various strengths, from a few grains to several drachms 
of the active ingredient to the ounce of simple ointment, according 
to the nature of the case and the effect desired. 

Caustics. — Under this head may be classed those substances and 
preparations which are discutient in their effect, as well as those 
which are truly caustic. To the former belong iodine, sapo viri- 
dis, mercurials, acetic acid, cantharides, and the like. Among the 



TREATMENT. 107 

stronger remedies, nitrate of silver occupies a conspicuous place; 
it is employed both in stick form and in solution, and is of service 
where a mild caustic or stimulating effect is desired, as in lupus, 
and in ulcers ; also in various superficial formations. 

Caustic potash, either in stick form or in solution, is a valu- 
able, potent, and thoroughly efficient escharotic. It is a powerful 
remedy, exceedingly rapid in its destructive effects, and should 
always be used with caution. It is applied with good result in 
new growths and hypertrophies, such as epithelioma, lupus erythe- 
matosus, lupus vulgaris, and wart, and in other affections. It may 
be employed either in its pure state, or weakened by admixture 
with other substances, as lime, in the preparation known as potassa 
cum calce. The chloride of zinc is likewise a strong caustic, pro- 
ducing its effect slowly, but occasioning great pain both at the time 
of the application and for some time after the operation. Chromic 
acid is a mild caustic, useful in epithelial hypertrophies, as warts 
and like affections. Ethylate of sodium and pyrogallic acid, both 
valuable, may also be here referred to. Arsenic is chiefly employed 
with other substances in the form of ointments and powders; it is 
prescribed in certain cases of lupus and epithelial cancer, and as a 
stimulating dressing in indolent ulcers. As a caustic it is slow but 
destructive in its action ; it possesses the peculiarity of attacking 
diseased tissue in preference to healthy structures. 

Nitric acid and the acid nitrate of mercury are well adapted 
for the treatment of venereal productions, as chancre, wart, etc. 
They should always be applied with care. Acetate of zinc, nitrate 
of zinc, carbolic acid, corrosive chloride of mercury, and other 
similar agents, are occasionally used for purposes of superficial 
cauterization. 

The great value of the mechanical treatment of certain diseases, 
especially by means of the dermal curette, may here be referred to. 
Hypertrophies, as wart, and new growths, as lupus vulgaris, scrofu- 
loderma, epithelial cancer, may all, in suitable cases, be treated 
successfully by this means. 

Parasiticides. — These are remedies which act destructively upon 
both the vegetable and the animal parasites of the skin. Sulphur 
and its compounds, including sulphite of sodium, hyposulphite 
of sodium, and sulphuret of potassium, are deserving of the first 
mention, and are effectual in both groups of diseases. Styrax 



108 TREATMENT. 

and Peruvian balsam are especially valuable in destroying the itch 
mite; staphisagria, cocculus Indicus, white precipitate, mercurial 
ointment, corrosive sublimate, and petroleum are the best remedies 
against the pediculus. The vegetable parasites are acted upon by 
a number of articles, among which the mercurials, more par- 
ticularly corrosive sublimate, the red and white precipitates, the 
yellow sulphate and the red sulphuret, are to be considered as 
holding a high position. Other remedies also serve the same 
end, as, for example, tar, creosote, carbolic acid, salicylic acid, 
thymol, boracic acid, veratria, goa-powder, carbonate of potassium, 
sulphuret of lime, borax, alcohol, iodine, cantharides, etc. 

Electricity. — This therapeutic agent may at times be applied 
with good result in certain affections, especially in those in which 
there is disturbance of the nervous system, as in herpes zoster, and 
in the neuroses; also in certain atrophies. The galvanic current — 
from five to fifteen cells — is that from which perhaps the best effects 
are obtained; but the farad ic current is also serviceable. The 
application may be either central or directly to the disease of the 
skin. Electrolysis, or the decomposition of tissues by means of the 
galvanic current, is of value in the treatment of certain tumors, 
tubercles, naevi, hypertrophies, connective-tissue growths, etc. It 
is accomplished by means of needles, in the place of ordinary 
electrodes, inserted in the tissues through which the current is 
discharged. The galvanic current is also useful in eradicating 
superfluous hairs. 



PEOGNOSIS. 

Concerning prognosis little is to be said in a general way. The 
question is with individual cases of disease rather than with classes. 
Diseases of the skin are either acute or chronic ; some are invari- 
ably acute in their duration, as in the case of the herpes group ; 
others are almost always chronic, as, for example, psoriasis. The 
majority of disorders, however, taking a view of the whole field, 
incline to chronicity; many of them are exceedingly obstinate, 
lasting years; others, as those of a congenital nature, usually 
continue throughout life. 

Anomalies of secretion are often rebellious to treatment, as is 
seen sometimes in seborrhoea and in hyperidrosis. The active 
hyperemias, as long as they remain such, are ephemeral derange- 
ments, and need occasion no anxiety. But it must be remembered 
that if the action of the cause is prolonged or carried beyond a 
certain point, the process becomes inflammatory, and the prognosis, 
consequently, more serious. 

Of inflammatory diseases as a class it is not possible to speak 
in general terms ; for while some always terminate favorably and 
within a definite period, others may end disastrously, as, for exam- 
ple, pemphigus ; this latter result, however, is rare. A number 
of the inflammatory affections tend to become chronic, lasting not 
infrequently months or years ; as instances, eczema, psoriasis, and 
non-parasitic sycosis may be cited. 

Hemorrhages are to be looked upon either in a favorable or 
in an unfavorable light according to their severity and extent. 
Hypertrophies, as a rule, have a benign character; they are slow 
in their course, and often continue a lifetime. Some of them are 
incurable. The same may be said of atrophies. 

Neoplasmata, or new growths, are either benign or malignant. 

109 



1 10 PROGNOSIS. 



The prognosis will depend upon the nature of the case under con- 
sideration. Lupus, syphilis, leprosy, carcinoma, and sarcoma must 
all receive grave prognoses; they are serious maladies, several 
of which frequently terminate fatally ; on the other hand, certain 
affections of this class, as fibrous molluscum, give rise to no trouble 
beyond annoyance and disfigurement. 

^ The neuroses are exceedingly variable in their duration; at 
times they yield readily to treatment, in other cases they are most 
obstinate. They are generally distressing to the patient. The 
parasitic affections are all curable. 



CLASSIFICATION. 

The use of a classification in the consideration of diseases of the 
skin is to group together, for purposes of study and reference, 
affections which are similar in their intimate nature. Various 
ways of accomplishing the same object have been proposed. The 
method which appears to me to be the most practically useful, 
and at the same time capable of the most extended and scientific 
elaboration, is based upon anatomy and pathology. 

The arrangement here presented is that of Hebra modified. It 
rests, as will be seen, upon anatomical and pathological grounds, 
with the exception of the last class, which is etiological. The first 
class includes functional disorders of the glandular apparatus un- 
accompanied primarily by inflammation. In the majority of in- 
stances, however, the nature of the pathological process, together 
with the particular structure involved, serves as the basis for the 
grouping of the diseases. 

CLASS I. ANOMAKLE SECRETIONIS— DISORDERS OF SECRE- 
TION. 

Seborrhcea. 1 

Comedo. 

Milium. Sebaceous Glands. 

Sebaceous Cyst. 

Hyperidrosis. ) 

Anidrosis. 

Bromidrosis. }- Sweat Glands. 

Chromidrosis. 

sudamen. j 

CLASS II. HYPEREMIA— HYPEREMIAS. 



Erythema Simplex. 

GO. i 

111 



\ Erythematous. 
Erythema Intertrigo. J 



112 



CLASSIFICATION. 



CLASS III. EXSUDATIONES— INFLAMMATIONS. 



Erytiikma Multiforme. 
Ekytiiema Nodosum. 
Urticaria. 

Eczema. 

Herpes. 
Herpes Zostbb. 

Herpes Iris. 

Miliaria. 

Pemphigus. 

Lichen Ruber 
Prurigo. 

Lichen Scrofulosum. 

Acxe. 

Acne Rosacea. 

Sycosis Non-Parasitica. 

Impetigo. 

Impetigo Contagiosa. 

Ecthyma. 

Psoriasis. 
Pityriasis Rubra. 

FuRUNCULUS. 
Anthrax. 

Dkbmatitis. 



Erythematous. 

Erythematous, Vesicular, Pus- 
tular, Papular, Squamous. 

Vesicular. 

Bullous. 
Papular. 

Pustular. 

Squamous. 

Phlegmonous. 

Erythematous, Vesicular, 
Bullous, etc. 



CLASS IV. HEMORRHAGIC— HEMORRHAGES. 
Purpura. ] Corium, etc. 



CLASS V. HYPERTROPHIC— HYPERTROPHIES. 

Pigment. 



Lentigo. 
Chloasma. 

N.EVUS PlOMEXTOSUS. 
MOLLUSCUM EriTHELIALE. 

(' lllosita8. 
Clavus. 

CORNU. 

Vebbuca. 
Ichthyosis. 

Keratosis Pilaris. 



Epidermis, Papillae. 



CLASSIFICATION. 



113 



Scleroderma 

morphcea. 

Sclerema Neonatorum. 

Elephantiasis Arabum. 

Dermatol rsis. 

Hypertrophy of the Hair. 
Hypertrophy of the Nail. 



. Corium. 



Hair. 

Nail. 



Albinism. 
Vitiligo. 

Canities. 



CLASS VI. ATROPHIA— ATPvOPHIES. 
L Pigment. 



Atrophia Cutis. 
Atrophia Senilis. 
Strijs et Macule Atrop 



ricje. J 



Corium. 



Alopecia. 
Alopecia Areata. 
Atrophy of the Hair. 

Atrophy of the Nail. 



Hair. 



Nail. 



CLASS VII. NEOPLASMATA— NEW GROWTHS. 

Connective Tissue. 



Keloid. 

Molluscum Eibrosum 

Xanthoma. 



Rhinoscleroma. 
Lupus Erythematosus. 
Lupus Vulgaris. 
Scrofuloderma. 
Lepra. 

Syphiloderma. 
Carcinoma. 
Sarcoma. 

NiEVUS Vasculosus. 
Telangiectasis. 

Lymphangioma. 

Neuroma. 



- Cellular. 



Bloodvessels. 

Lymphatics, 
Nerves. 



114 CLASSIFICATION. 

CLASS VIII. NEUROSES— NEUROSES. 

HYPERESTHESIA. 

DxBMATALGIA. I Hyperesthesia. 



Pruritus. 

An.k-ihesia. J Anaesthesia. 

CLASS IX. PARASIT.E— PARASITES. 

Tinka Favosa. ~i 

(T. ClRCINATA. I 
T. Tonsurans, l Vegetable. 
T. Sycosis. 
Tinea Versicolor. j 

Scabies. ] 

Pediculosis Capitis. I 

Pediculosis Corporis. \ Ammal - 
Pediculosis Pubis. 



PART II. 

SPECIAL DISEASES. 



CLASS I. 



ANOMALI.E SECEETIONIS— DISOEDEES OF 
SECEETION. 

This class comprises an important group of diseases. It is 
composed of the various functional disorders of the sebaceous 
and sweat glands. The affections here considered are strictly 
those of abnormal secretion. Diseases of the glands accompanied 
by inflammation, as, for example, acne, find their place under 
Inflammations. 

SEBORRHEA. 

Syn., Pityriasis ; Stearrhoea ; Steatorrhoea ; Fluxus Sebaceus ; Cutis Unc- 
tuosa ; Acne Sebacea ; Seborrhagia ; Tinea Furfuracea ; Tinea Amiantacea ; 
Tinea Asbestina; Ichthyosis Sebacea ; Dandruff ; Danclriff; Germ., Scbmeer- 
fluss; Gneis ; Fr., Acne Sebacee. 

Seborrhea is a disease of the sebaceous glands character- 
ized BY AN EXCESSIVE AND ABNORMAL SECRETION OF SEBACEOUS 
MATTER, FORMING UPON THE SKIN AN OILY COATING, CRUSTS, OR 
SCALES. 

Symptoms. — Seborrlicea may appear upon any portion of the 
body, though, like the majority of cutaneous affections, it has 
favorite localities for its development. By far the most common 
seat is the scalp; next in frequency it occurs about the face. Upon 

115 



] 1 'J DISORDERS OF SECRETION. 

the body it is Been mos! often about the back, between the scapulae, 
and upon the chesi over the region of the sternum. It occurs at 
all periods of life, from birth to mature age. In newly born in- 
fants it constitutes the vemix caseosa, or smegma, and may be pres- 
ent in a Blight degree or as a thick coating involving the whole 
body, and is to be viewed as a physiological rather than a patho- 
logical process. It is liable to remain about the scalp in infants 
throughout the first few months of life, in the form of a more or 
Less compact, dirty-yellowish, crusted or scaly accumulation. 

The course of the disease is variable. At times it is a very 
slight affection, disappearing either spontaneously or with simple 
treatment. In other instances it is severe, and may continue for 
years unless properly managed; even with judicious treatment it 
may prove obstinate. The general condition of health not infre- 
quently influences its course in a marked manner; as the tone of 
health improves, the glands, as a rule, tend to assume normal action. 

The state of the skin itself varies according to the amount of 
disturbance as well as with the character of the secretion. In the 
majority of instances the disease is not inflammatory, there being 
neither decided redness of the surface nor heat. In some cases, 
on the other hand, intense hypersemic or even inflammatory signs 
are present. The process tends to vary in intensity from time 
to time. The subjective symptoms are variable. Itching is fre- 
quently complained of, and is at times the source of considerable 
distress. In the more inflammatory forms, as seen sometimes 
about the cheeks, decided burning sensations are complained of. 

The general health of patients suffering from seborrhoea, espe- 
cially in marked examples, is usually below standard. They fre- 
quently suffer from amende or chlorotic symptoms, characterized 
by pallor of the face, cold hands and feet, and other signs to be 
spoken of in considering the subject of etiology. The disease is 
generally better in summer than in winter, and may even disappear 
in part or wholly during the hot weather. It is liable to relapse. 

There are two distinct varieties of seborrhoea, which are desig- 
nated respectively seborrhoea oleosa and seborrhoea sicca, according 
to the character of the secretion poured forth. Sometimes they are 
encountered together, usually upon different regions, as the scalp 
and face. Inasmuch, however, as the clinical appearances are 
different, I shall consider them separately. 



SEBOERHCEA. 117 

Seborrhcea Oleosa. — This variety appears in the form of 
an oily, greasy coating upon the skin, which gives it an unctuous 
look and feel. The secretion is decidedly oily in character, and 
may be in such quantity as to collect in minute drops upon the 
surface, when it will be seen to be a clear yellowish fluid, and 
fatty in its composition. It shows itself upon both the hairy and 
the non-hairy portions of the body. Its most common seat is the 
region of the face, and more particularly the nose and forehead. 
Here it is generally observed as a greasy layer, often containing 
more or less dust, looking at times as though the skin had been 
smeared Avith some dirty ointment. This product is given forth 
in varying quantities ; at times it is formed slowly and occasions 
but slight inconvenience to the patient, who manages to remove it 
by repeated washings. In other cases, however, it is poured out 
in excess, and constitutes an annoying disorder. It is not often 
seen upon the hairy parts of the body. Upon the scalp it occurs 
more especially in those who are bald, giving the skin of the head 
the appearance of having been oiled. Marked examples of sebor- 
rhcea oleosa are not common. 

Seborrhcea Sicca. — This is the variety usually encountered. 
It manifests itself upon both hairy and non-hairy regions. It 
consists in the formation of dry, more or less greasy masses of 
scales or crusts, of a grayish, yellowish, or brownish-yellow color, 
which have a tendency to adhere to the skin. A mixed form of 
the disease is also frequently met with, both varieties here and 
there or from time to time manifesting themselves. 

Seborrhcea must be considered first as it occurs upon the hairy 
parts, more particularly the scalp. 

Seborrhcea Capitis. — This is not only the commonest local 
form of the disease, but also the most important, on account of 
the disfiguring results which are likely to follow it. It is one of 
the most frequent sources of premature baldness. The affection 
is marked by the free formation of grayish or yellowish scales, 
which are ordinarily seen uniformly distributed over the scalp. 
More rarely they occur in the form of one or more variously sized 
patches. The scales may be either small, dry, and pulverulent, 
situated loosely upon the surface and detached from the hairs, or 
they may be in thin or thick crust-like masses, adhering to the 



118 T-I-ORDERS OF SECRETION. 

>kin in the form of a coating. Tn these latter cases the hairs are 
often, :i~ it were, pasted down to the scalp. In either instance the 
scales fall off, and collect about the shoulders of the patient. If 
the scalp be not cleansed and the accumulations removed from 
time to time, thick masses or cakes may form and completely 
envelop the region, preventing the hair from growing. The hair 
itself sooner or later becomes affected, is lustreless and dry, and 
soon commences to fall out. This is but the beginning, the pro- 
ventually terminating in more or less complete, permanent 
1— of hair, especially about the vertex. The follicles have been 
so Inn- diseased by the morbid secretion of their glands that they 
have become structurally altered, and in many instances obliterated. 

If the scales be detached, the scalp is usually seen to be of a dull 
grayish or bluish-gray color, a peculiarly dead, ansemic hue, which 
is characteristic. This appearance is almost always present in 
chronic sluggish cases, where the general health is obviously im- 
paired. In other cases more or less hyperemia exists. The dis- 
ease may attack the whole of the scalp, uniformly, or only in 
places; the former course is commonly observed. The crown of 
the head is its favorite locality. In connection with seborrhcea of 
the scalp, mention may be made of the disease as it occurs upon the 
hairy parts of the face, as the moustache, whisker, and eyebrows, 
where it may occasion annoyance. The symptoms are similar to 
those of seborrhcea of the scalp, though usually they are less 
marked. 

A condition of the scalp is sometimes met with where the nature 
of the process appears doubtful. It is questionable to what ex- 
tent the sebaceous glands are primarily involved, and whether the 
affection should not be regarded rather as inflammatory in nature. 
It i- characterized by a more or less hyperaemic or slightlv in- 
flamed state of the scalp, accompanied with the formation of fine, 
dry, epithelial scales, and sometimes burning or itching. It may 
run an acute or a chronic course, and i< subject to exacerbations. 
1' occurs in those whose hair is abundant as well as in those in 
whom the hair is scanty. This form of disease has received 
careful study from Pincus,* Piffard,f and Van Harlingen,J who 

Vinhow's Archiv, Bel. xli., 1807, p. 322. 
t Diseases of the Skin, New York, 1876, p. 102. 
% Archives of Dermatology, April, 1878, p. 102. 



SEBORRHCEA. 119 



SIMPLEX. 

\Seborrhgea Faciei. — Upon this region it is mostly observed 
between the ages of fifteen and thirty. It occurs about the fore- 
head, on the cheeks, and over the nose, involving any one of these 
parts alone, or attacking all of them at the same time, and tends 
to assume the oily variety, although the dry form is also seen fre- 
quently.* The skin may or may not be hypersemic; more rarely 
it is inflammatory. At times it is reddish and irritable, and ac- 
companied with burning or itching, especially in the dry variety ; 
in the oily form these symptoms are seldom observed. Seborrhoea 
oleosa may exist here in all degrees, from a very slight to a marked 
disorder. It is seen as a shining, greasy film over the skin, gen- 
erally showing itself about the forehead, cheeks, and nose. 

Seborrhoea sicca appears as a more or less compact, thin or thick, 
greasy secretion, often in the form of a mask to the part. It ad- 
heres to the skin, and is bound down to it by the prolongations of 
sebaceous matter which come directly from the follicles. These 
sebaceous crusts are usually seen about the cheeks, nose, and fore- 
head, and are disfiguring. In color they are generally yellowish, 
but they may be greenish, brownish, or even blackish. Particles 
of extraneous matter of one kind or another at times collect upon 
the surface, and may be incorporated into the crust. The process 
is usually active, the crusts being readily replaced in spite of fre- 
quent washings and other means employed for their removal. 
Itching and burning sensations may attend the disease in this lo- 
cality ; these symptoms, however, as a rule, are not constant, but 
are subject to exacerbations, keeping pace with the activity of the 
process. In other cases, of a less hypersemic type, no symptoms 
of this kind are experienced. 

Seborrhoea. Nasi. — This also calls for special attention. The 
nose is ordinarily reddish, shining, and oily. The redness is apt 
to give rise to more anxiety to the patient than the abnormal se- 
cretion. The nose is not increased in size, nor is it swollen or hot, 
but, on the contrary, is often cold. The openings of the follicles 
are noted to be more or less enlarged and patulous, a condition 
showing the absence of proper tone and vitality in the part. 

* See Plate "W in mv Atlas of Skin Diseases. 



120 MSORDERS OF SECRETION". 

Seborrhcea of the fare, and in particular of the nose, is one of 
the seqnelse of variola, and often continues for a considerable time 
after the original disease. 

SEBORRHCEA GENITALIUM. — On account of the great number 
and size of the glands about these regions, they are a frequent seat 
of seborrhcea, The condition is equally common in both sexes. 
Jn the male the glans penis and sulcus are the localities where 
it is ordinarily met with, forming a whitish, soft, cheesy mass, 
which collects about the parts. The same product is found in the 
female about the labia and clitoris. It may exist to aslight degree, 
scarcely constituting disease, or it may become copious and occasion 
inflammatory symptoms, which in the male, in cases of prolonged 
prepuce, may result in balanitis. Decomposition of this sebaceous 
matter takes place rapidly, and is greatly favored by moisture and 
heat. 

Seborrhcea Corporis. — It is necessary to speak of the affec- 
tion as it is encountered here, because it assumes features which 
are different from those which are seen elsewhere. The back, be- 
tween the scapulae, and, in front, the clavicular and sternal regions, 
are 1 the two localities where the disease generally appears. Both 
of these localities are often attacked at the same time. 

Upon the back, patches are formed of varying size and shape ; 
they may be the size of a finger-nail or as large as a silver dollar. 
I rsually they arc small. They may exist separately, but they more 
often coalesce, forming an irregularly shaped, ill-defined patch. 
They are pinkish or reddish in color, but, being partly covered 
with yellowish or grayish scales, often have a pale look. The 
scales are rarely in any quantity; they are usually loose, and are 
in many cases altogether wanting, having been detached and 
rubbed away by the friction of the clothing. The mouths of the 
follicle- are observed to be open and enlarged. The patches some- 
times merge into one another, and thus involve the shoulders and 
upper part of the back as one imperfectly developed patch, re- 
sembling in general appearance marginate tinea circinata. Acne 
papules and pustules, usually small, are occasionally seen here 
and there about the borders of the disease. 

Upon the chest the patches generally assume a circular shape, 
and are made up of a pale reddish base, surmounted with pellicle- 
like epidermic scales, which are of a dingy grayish or yellowish 



SEBORRHCEA. 121 

color, and are greasy or withered and dry. They usually have a 
well-defined outline ; they may be either discrete, as is often the 
case, or they may have run together, forming one patch. There 
may be one or two or more present. Seborrhoea of this region 
may closely resemble tinea circinata. It is very slow in its course, 
and is subject to changes, being from time to time better and worse. 
It may disappear partially or completely during hot weather. 

Etiology. — The causes which give rise to seborrhoea are nu- 
merous, but depend for the most part upon an impairment of 
the general health. Before referring to these, attention may be 
directed to the fact that a certain amount of sebaceous matter upon 
the skin is normal, and conducive to the preservation of this mem- 
brane. In the newly-born infant, for example, the smegma serves 
a valuable physiological function. It is only when the secretion 
is produced in excessive quantity or in abnormal form that the 
condition is to be regarded as disease. 

The causes giving rise to the two varieties of the affection are 
the same, peculiarities of the individual determining whether the 
process will take on the form oleosa or sicca. Persons with light 
hair and complexion are more prone to the dry variety, while those 
with dark hair and skins commonly exhibit the oily form. It 
was Hebra who first pointed out that seborrhoea is in many in- 
stances dependent upon a chlorotic or anaemic state. This will in 
both sexes be found to be a common cause. Seborrhceic patients 
are, as a rule, thin and pale ; have doughy complexions, often 
with a tendency to slight papular acne or comedones ; and are 
poorly nourished or strumous. The various functions of the body 
are often deranged ; especially is this the case in females, where the 
menses and the bowels are usually more or less irregular. Hence 
it is that seborrhoea is so frequent during the period of adoles- 
cence, when all the forces of the body are brought into action, and 
the functions belonging to adult life are regulating themselves. 
The disease occurs in both sexes, but is more often encountered in 
females. It may show itself at any time of life, although it is 
most frequently met with during early adult age. As I have 
already pointed out, all those conditions characterized by general 
debility and faulty nutrition, from whatever source, may serve as 
causes. Having thus referred to some of the known causes, it 
must also be stated that it may exist upon persons who appear to 



122 DISORDERS OF SECRETION. 

be iii otherwise excellent health, no appreciable origin for the 
disorder being recognizable. Such cast's, however, are rarely 
obstinate and generally give way to local treatment. 

Pathology. — Seborrheas is a functional disorder of.the sebaceous 
glands, consisting in an increased and usually altered flow of the 
Becretion, together with a variable amount of epithelial scales 
derived from the glands and their ducts. The sebum given out 
may be either oily or firm in its consistence, this difference giving 
rise to the varieties of the affection. In health it is known that 
the sebaceous glands discharge a variable amount of sebum in 
different localities; some parts of the skin, as the scalp, needing 
an abundant supply, other portions requiring but a small amount. 
Seborrheas is most common where the glands are normally most 
active, as upon the scalp, nose, and cheeks. It is a functional de- 
rangement of the glands, no alteration, as a rule, taking place in 
their structure. At the same time, if the process be allowed to 
run on indefinitely, certain organic changes occur, as atrophy of 
the glands, follicles, and adjacent structures. This is not infre- 
quently observed upon the scalp. The product of seborrheea, ex- 
amined with the microscope, is found to consist of an amorphous, 
fatty, slightly granular mass, together with epithelial cells, coming 
from the lining walls of the glands and their ducts. The sebum 
and the scales vary as to proportion. In some cases the epithelial 
cells are greatly in excess of the sebaceous matter, the product 
thrown off being mainly epithelium more or less altered in 
character. 

Diagnosis. — Seborrheea is a disease whose features vary con- 
siderably with the intensity of the process. It also presents 
different appearances upon the various regions of the body. 
There are several affections which at times resemble it closely. 
Upon the scalp it may readily be mistaken for dry eczema. 
Seborrheea, when present, usually occupies the greater portion of 
the scalp more or less uniformly; eczema is apt to be localized, 
appearing in distinct patches. The scales are generally abundant 
in seborrheea and form rapidly; in eczema they are ordinarily 
scanty. The skin of a patch of seborrheea is usually pale in color; 
that of eczema is always more reddish, and is infiltrated more or 
less and t bickened. Seborrheas is always a dry disease; in eczema 
a history of moisture at some period in the course of the affection 



SEBOEEHCEA. 123 

is very frequently obtainable. The itching of seborrhoea is seldom 
so intense as that of eczema. About the face it may also resemble 
eczema, especially the erythematous variety. The thick sebaceous 
crusts which occasionally occur upon the cheeks at times look not 
unlike those of vesicular eczema ; but the history of the disease 
will aid in establishing the diagnosis. 

Seborrhoea bears even a closer resemblance to psoriasis, whether 
occurring on the scalp or on the body. In seborrhoea the disease 
is usually uniformly diffused over the scalp ; in psoriasis the 
patches are, as a rule, irregularly dispersed, with healthy skin 
between them; their outlines, moreover, are generally sharply 
denned. In seborrhoea the scales are minute or caked, grayish 
or yellowish in color, and have a greasy feel; in psoriasis they 
are dryer, more abundant, much larger, thicker, and whiter. In 
seborrhoea the scalp is only exceptionally inflamed; frequently 
it is pale, ausemic, and leaden in color. In psoriasis the scalp 
beneath the scales is always reddish and inflamed. This latter 
point, it appears to me, is one of great value as an aid to diag- 
nosis. The histories, moreover, of the two diseases are different 

Seborrhoea of the scalp can scarcely be confounded with tinea 
tonsurans, but upon the chest it not infrequently looks like tinea 
circinata. Its history, the slowness of its course, and the greasy 
feel and appearance of the scales, together with their microscopic 
examination, will always serve to distinguish it from this disease. 

The striking similarity between seborrhoea and the milder forms 
of lupus erythematosus renders the diagnosis now and then diffi- 
cult. It must here be remembered that lupus erythematosus not 
infrequently makes its first appearance as a congestive seborrhoea. 
When fully developed, however, the distinctive features of lupus 
are sufficiently marked not to permit of error. Seborrhoea seldom 
possesses the line of demarcation seen in lupus erythematosus; nor 
is it usually attended with such inflammatory signs. Seborrhoea, 
moreover, is never accompanied by infiltration and thickening, 
both constant symptoms of lupus. The patches of seborrhoea are 
pinkish or reddish, but seldom of a deep tint ; in lupus they may 
also be pinkish, but more often are dark red or violaceous, and 
covered with tenacious scales. Pathologically, seborrhoea is a 
functional disorder ; lupus is a new growth. Seborrhoea, finally, 
differs from lupus in that it is not followed by cicatricial tissue. 



] 2 I DISO RDEES OF SECRETION. 

Treatment. — Local and constitutional treatment are both to be 
considered. They may be employed separately or together. In- 
ternal remedies are to be directed in those cases where there is 
obvious functional disturbance of some of the organs of the body, 
OT where th.re is need for constitutional treatment. The history 
of the patient, and of the course of the disease, should always be 
carefully inquired into. The causes upon which the affection 
depends are often so obscure as to call for attentive study. The 
indications will be those symptoms already referred to in speaking 
of the etiology of the disease. 

It is of importance that the patient be surrounded by proper 
hygienic intluences. Fresh air and exercise are valuable aids in 
the treatment of a certain class of seborrheas in young persons, 
especially women. The food should be as nourishing as possible. 
Cod-liver oil in full doses should be prescribed, and taken for a 
considerable time: it will be found of service in many cases. Iron 
i- also of value, as in the following formula: 

R Tinet. Ferri Chloridi, f^i ; 
Acidi Phosphorici dil., 151 ; 
Syrupi Limonis, f^ii. 

M. — Sig. Half a teaspoonful three times daily with a wine- 
glassful of water. To be taken through a glass tube. 

Other ferruginous preparations may be ordered as age and other 
conditions may require. Xot infrequently arsenic in small doses 
acts beneficially. It may also be advantageously prescribed with 
wine of iron : 

R Lif]. Potassii Arsenitis, ftji ; 

Vini Ferri, fgiv. 
M. — Sig. One teaspoonful three times daily directly after 
meals. 

Sulphur and its compounds, especially the sulphides, remain to 
be mentioned, and are valuable remedies. The doses should be 
small, and the treatment continued for weeks or months. The 
sulphide of calcium may be given in doses of one-tenth or one-fifth 
of a grain three or four times daily. 

The Ideal treatment is also of the greatest importance. It must 
vary somewhat as one region or another is the seat of disease. 



SEBORRHGEA. 125 

Seborrhcea capitis calls for special directions. If there be an ac- 
cumulation of sebum and scales, they should be removed at once 
and the surface thoroughly cleansed, that a view of the skin 
and follicles may be obtained. At times the mass of sebaceous 
material is so thick and inspissated that ordinary washing with 
soap and water is not sufficient to cleanse the head. When this is 
the case, one of the bland oils should be first rubbed in and allowed 
to remain for a while. Either olive oil or almond oil is to be pre- 
ferred for this purpose. The patient is directed to pour a quantity 
of the oil upon the head, and to have the scales saturated with it. 
Enough must be applied to soften and loosen the mass. The 
operation is best performed at night-time. A close-fitting cap, 
made of flannel, should be put over the head, and a bandage 
worn, in order to keep the oil from soaking through. In the 
morning the cap is to be removed and the scalp thoroughly 
washed with warm water and soap. Ordinary hard soap is usually 
not strong enough. Soft soap alone with water or dissolved 
in alcohol, according to the following formula, will be found 

valuable : 

R Saponis Viridis, §viii ; 

Alcohol is, f^iv. 
Solve et filtra.* 
Sig. To be used as a soap-wash or shampoo. 

Equal parts of soap and glycerine will also be found useful for 
the same purpose. A tablespoonful may be poured upon the head, 
together with a small quantity of water, which with friction will 
produce a copious lather. This is to be rubbed into the scalp, and 
afterwards washed out with warm water. The hair should now 
be dried by means of soft towels ; if long and thick, it may be 
dried with the heat of a fire. Concerning the cutting of the 
hair to facilitate the treatment, I would remark that the process 
is never necessary. The applications may be made with as much 
success when the hair is long as when it has been cut. The 
washing and drying operation performed, it is now necessary to 
apply some oily or fatty substance. If this be not done, both the 

* This preparation, and the mode of its employment, were introduced to 
the profession by Hebra. It may be made in various proportions, and per- 
fumed to please the individual. Cologne water may be used in the place of 
alcohol. 



126 DISORDERS OF SECRETION. 

hair and the Bcalp will become dry and harsh. The kind of oil 
or pomade to be used will depend in a measure upon the con- 
dition of the scalp. If irritated, one of the simple oils, as almond 
oil, or vaseline, the latter preferably benzoated in the strength of 
a few grains to the ounce, should be applied. Glycerine and 
water, one part to four or eight, also constitutes an excellent 
mild oily preparation. Glycerine and alcohol, one part to two or 
four, will sometimes prove grateful, especially in those cases where 
the scalp is dry, hypercemic, and heated. In the majority of 
instances, however, stimulating preparations will be found of 
greatest benefit. Carbolic acid often acts favorably in combina- 
tion with an oil and alcohol, as follows : 

R 01. Ricini, f^ii ; 

Acidi Carbolici, TT^xxx ; 

Alcoholis, f^iss ; 

01. Amygdal. Amar., n\,x. 
M. — Sig. To be applied after washing. 

Tincture of cantharides, tincture of nux vomica, tincture of cap- 
sicum, chloral, corrosive sublimate, and other similar substances, 
may in like manner be employed where direct stimulation is indi- 
cated. The following formula may also be recommended : 

R Tinct. Cantharidis, f^iii ; 
Tinct. Capsici, f^iii ; 
01. Ricini, f£ii ; 
Alcoholis, fgii ; 
Spts. Rosmarini, f^i. 

Chloral may be used in the strength of from twenty to forty 
grains to the ounce of water with the addition of a small quantity 
of glycerine. Anderson gives the following formula for a wash 
containing corrosive sublimate : 

R Hydrargyri Chlor. Corros., gr. xii ; 

Glycerinse, f^iv ; 

Alcoholis, fgv ; 

Spts. Rosmarini, fcjiv. 
M. — Sig. Apply twice daily. 

Ointments are also used with good effect. They should be used 
in small quantity, and well rubbed into the scalp. Precipitated 



SEBORRHCEA. 127 

sulphur, in the strength of from half a drachm to two drachms 
to the ounce, must be first mentioned. It is our most valuable 
remedy. The red oxide of mercury and ammoniated mercury are 
also useful, in the strength of from five to fifteen grains to the 
ounce, and may be prescribed with one of the petroleum ointments, 
as follows : 

R Hydrargyri Oxidi Eubri, gr. x ; 
Ungt. Petrolei, ^i ; 
Bals. Peruvians, gr. v. 

M. Ft. ungt. 

Sig. A small quantity to be applied once or twice daily. 

Ointment of the nitrate of mercury two drachms, to vaseline 
six drachms ; and tannic acid thirty grains to the ounce of vase- 
line, may both be mentioned as useful formulas. The prepara- 
tions of tar are also very useful. One drachm of liquid tar to 
the ounce of ointment will often be found valuable. The oil of 
cade may likewise be employed. 

Having enumerated some of the preparations that may be em- 
ployed, further directions as to the frequency of these applications 
remain to be given. According to the activity of the process, the 
quantity of the scales, itching, and the general condition of the 
head, the cleansing is to be repeated every day, every other day, 
or as occasion may seem to require. The oil or ointment should 
be used after each washing. At times, where the scales are not 
plentiful, it is expedient to apply the oil or ointment occasionally 
without previous cleansing. The treatment should be persisted in 
for weeks or months, until in fact improvement takes place. 

The local treatment of the face, body, and non-hairy regions is 
somewhat similar to that just described for the scalp. The masses 
of scales or the sebaceous crust are to be removed by frequent 
washings or warm baths, together with soaps of suitable alkalinity. 
After being well cleansed, sulphur ointments and lotions, alcoholic 
lotions, mercurial ointments, bland oils or ointments, are to be used 
as may appear indicated. The kind of application to be preferred 
will depend upon the condition of the part, upon the variety of 
the disease, upon the hyperemia present, and finally, after trial, 
upon those remedies which appear to act most beneficially. 

Prognosis. — This will depend somewhat upon the general con- 
dition of the patient. As a rule, the affection is obstinate, yield- 



128 DISORDERS <»f SECRETION. 

ing only after tn atment lias been continued for some time; months 
arc frequently found to be necessary to alter the abnormal secre- 
tion. On the other hand, some cases yield very readily. The 
most serious form is usually observed on the scalp, where it has 
lasted for some time and the hair has already begun to fall out; 
in these cases the prognosis is not favorable for a speedy termi- 
nation, or for the restoration of the hair. When baldness has 
already occurred, a future growth of hair is not to be looked for, 
although much may be accomplished towards restoring to a state 
of health those follicles which have not been seriously involved. 
In infants the affection seldom occasions difficulty, being usually 
amenable to simple remedies. 



COMEDO. 

Comedo is a disorder of the sebaceofs glands character- 
ized by yellowish or whitish pin-point and pin-head sized 
elevations containing in their centre blackish points. 

Symptoms. — It is observed for the most part about the face, 
neck, chest, and back. Each single elevation or papule is desig- 
nated a comedo, and they are usually spoken of in the plural as 
comedones. They may be very numerous or few; usually, where 
there is a tendency to their formation, they exist in numbers, 
giving a brownish or blackish, speckled or punctate appearance to 
the part. Their common situation is about the forehead, cheeks, 
and chin. As in the case of acne, they are usually irregularly 
distributed. In size they are small, varying from a pin-point to 
a pin-head. At times they form in great numbers upon the face, 
and are then disfiguring, giving the individual the appearance of 
having had minute grains of powder implanted in the skin. The 
skin has a dirty, greasy, unwashed look. The condition is not 
attended with any sign of inflammation, unless complicated witli 
acne, and gives rise to no subjective symptoms. It is, however, 
very frequently associated with acne, to which disease it is in- 
timately allied. It occurs principally in young people, perhaps 
mosl often at the age of twenty or thereabouts, but it is also 
seen in older persons. The lesions come and go from time to 
time, although their course is naturally sluggish and chronic. 
Their continuance, however, depends upon the nature of the cause 



COMEDO. 129 

and other circumstances. Without interference they may last for 
years. Occasionally, notwithstanding the most energetic treatment, 
they prove rebellious. 

Etiology. — It is frequently observed to occur in those whose 
skins are improperly cared for. The true source of the disease is, 
I think, to be found, certainly in many instances, in disorders of 
the important functions of the body, as we so often observe in the 
case of acne. Persons suffering from comedones are generally 
noticed to have a thick, muddy-looking skin, plainly showing a 
want of activity not only in the glandular structures but also 
throughout the whole integument. More or less constipation or 
irregularity of the bowels, with dyspepsia, is frequently present ; 
while patients will often be observed to exhibit a state of hebetude 
denoting a general condition of sluggishness with reference to the 
various functions of the body. In young women chlorosis and 
menstrual difficulties are likely to be present. 

Pathology. — The affection has its seat in the sebaceous glands 
and ducts. It consists of an accumulation of sebum and epithelial 
cells in the glands and follicles, dilating the ducts to such an extent 
as to produce the point or elevation upon the surface. According 
to Unna,* the dark points so characteristic of the disease are due to 
pigment, existing partly in the form of free granules and partly 
diffused in the horny cells at the upper part of the comedo. The 
pigment is black, blue, or brown. The process is an inactive one, 
and occasions little or no disturbance in the surrounding tissues. 
The obstruction may relieve itself, or it may continue, distending 
the gland until a papule is formed. The comedo is readily removed 
by pressure exerted upon its walls, when the mass is seen to con- 
sist of sebaceous matter with epithelial cells, dirt, or other foreign 
particles. The cells are filled with oil globules and exhibit signs 
of fatty degeneration. Small hairs are frequently foUnd in these 
masses, and also at times the microscopic demodex folliculorum. 
This little mite, however, is not to be viewed as in any way the 
cause of the disorder. It is altogether inoffensive in character, 
and is found to exist in healthy follicles as often as in comedones. 

Diagnosis. — No difficulty can arise upon this point. The affec- 
tion is so commonly observed upon the face, that its features are 

* Yirchow's Archiv, Bd. lxxxii. 



130 DI80BDEB8 OF BECKETION. 

well known to all. As stated, it is frequently encountered in 
connection with acne; the two processes, however, may be dis- 
tinguished by the absence of inflammatory symptoms in comedo. 
Milium is Likewise a disorder closely allied both in nature and in 
appearance to comedo. They differ in that milium contains no 
open duct and is consequently without the characteristic black 
point of comedo. Milium is seated just beneath the epidermis, as 
a circumscribed whitish body, and cannot be forced out of the skin 
without rupturing OT first incising its covering. 

Treatment. — Local treatment suffices in many cases to relieve 
the condition. Frequent hot baths, with soft soap or equal parts 
ip and alcohol, or soft soap and glycerine, likewise equal 
parts, followed by friction, often alone serve to stimulate the glands 
t<> normal activity. In addition to this, each comedo is to be treated 
separately, by expressing the contents of the follicle, which may 
be accomplished by means of a watch-key of suitable bore placed 
directly over the black point and pressed upon. The same residt 
may be obtained by squeezing the comedo between the thumb nails. 
A certain number of the lesions should be treated in this manner 
each day, until all the follicles have been emptied; when they again 
become plugged, the same process is to be repeated, and from time 
to time, until healthy action is assumed. Another mechanical 
mode of treating the lesions consists in the use of the dermal 
curette, or scraper. Frictions with fine sand may also be resorted 
to, as recommended by Ellinger. Stimulating lotions and oint- 
ments, especially the sulphur compounds, are of the most service. 
The following may be used with good result : 

R Sulpburis Praeipitati, ^ii ; 

Glycorinaj, fgi ; 

Adipis, jjvi. 
M. Ft. ungt. 
Sig. To be well rubbed in at night. 

Alcoholic lotions, with sulphur, as, for example, those referred 
to in the treatment of acne, may also be employed with benefit. 
Equal parts of sulphur, glycerine, alcohol, carbonate of potash, 
and ether, will be found a useful application, used every second 
or third night where the skin is irritable. The various remedies 
useful in acne may also be resorted to in obstinate cases. Where 



MILIUM. 131 

the skin becomes inflamed or harsh under the use of stimulating 
remedies, weak alkaline ointments, as half a drachm of borax or 
of bicarbonate of soda, with ten or fifteen minims of glycerine, to 
the ounce, may be used. Together with the local measures, treat- 
ment for the improvement of the general health should at the same 
time be instituted, as the case may demand. Derangement of any 
of the functions of the body should be corrected ; proper diet and 
hygiene should be directed, and strict attention given to the ordi- 
nary rules for promoting health. The preparations of iron and 
arsenic are of benefit in many cases, especially in chlorotic young 
women. Cod-liver oil I have also found to be of service. 

Prognosis. — As a rule, no difficulty is encountered in the re- 
moval of comedones, a few months usually sufficing for their cure. 
Occasionally, however, they are remarkably obstinate, new ones 
returning from time to time in the same glands. The patient 
should always be encouraged, for, with a well-directed treatment, 
a favorable result must sooner or later occuiv 



MILIUM. 

Syn., Grutirm ; Tubercula Miliaria; Follicular Elevations; Tubercula 
Sebacea ; Acne Albida ; Pearly Tubercles ; Strophulus Albidus. 

Milium consists in the formation of small, roundish, 
whitish, sebaceous, non-inflammatory elevations, situated 
in the skin beneath the epidermis. 

Symptoms. — Milia have their seat for the most part upon the 
face, especially on the forehead and about the eyelids ; they may, 
however, occur on other parts of the body. They vary as to size 
from a pin-point to a small pea ; their ordinary size is that of a 
millet-seed, — hence the name. They may occur singly or in great 
numbers. As a rule, a half-dozen or more are met with scattered 
over the upper part of the face. In color they are whitish, pearl- 
colored, or yellowish, and often have a translucent look, as though 
they contained fluid. In form they are rounded or acuminated, 
and may be felt as more or less firm or hard bodies embedded 
superficially in the skin. They form very gradually and slowly, 
and when fully developed are not apt to undergo any change, 
but may remain in the same state for years. No inconvenience, 
beyond disfigurement, is occasioned by their presence. They are 



1^,2 i>i~->i;uers OF SECRETION. 

sometimes md with in connection with acne and comedo; in other 
cases they constitute the sole disorder. They are met with more 
commonly upon women than upon men, and usually first show 
themselves at middle age. 

Jn connection with milium, the so-called stones of the skin, or 
< DTANEOUS CALCULI, may be referred to. They are usually milia 
or sebaceous concretions which have undergone metamorphosis 
into hard, calcareous, stone-like masses; they are met with only 
rarely. Dr. E. F. Foster,* of Boston, has reported a ease, where 
the formation, situated on the side of the face of a woman nine- 
teen years of age, gave rise to a small, oval, hard tumor. After 
excision it had the appearance of a small urinary calculus. It was 
f.und to be densely calcified and to consist mainly of phosphate of 
lime, together with a small amount of carbonate of lime, epithelial 
debris, and fatty matter. 

Etiology. — The causes of milium must be viewed as being simi- 
lar to those which give rise to comedones and cysts of the sebaceous 
glands. In some cases, however, no cause can be assigned for its 
appearance. 

Pathology. — The affection has its seat in the sebaceous glands. 
It consists in an accumulation of sebum within the gland, which, 
owing to obliteration of the duct from some cause or other, is un- 
able to escape. No sign of aperture is to be found. The contents 
cannot be srpieezed out, for the formation is completely enclosed. 
If carefully examined, it will be seen that the lesion is situated 
just beneath the epidermis which constitutes its external covering. 
Neumann and others have found upon section that the covering 
proper is either the wall of the hair-follicle or that of the gland 
itself, and that the larger milia contain connective-tissue septa 
running through them. The mass is made up of sebaceous matter 
closely packed together and tending to become inspissated and 
calcareous. 

Diagnosis. — Although milium and comedo are similar in ap- 
pearance, they differ in one important anatomical particular. In 
milium there exists a distended but enclosed or encysted gland 
without opening; in comedo the duct of the gland is always patu- 
lous upon the surface. Milium usually exists alone, the rest of 

* Boston Med. and Surg. Jour., Jan. 30, 1879. 



SEBACEOUS CYST. 133 

the skin being in good order ; comedo is commonly associated 
with general derangement of the skin. The blackish point of 
comedo is another conspicuous feature. The disease can scarcely 
be confounded with xanthoma, a disease which usually has its seat 
about the eyelids, but which is of a very different nature. 

Treatment. — The treatment consists in opening the little tumors 
by means of a knife and removing the contents. Piffard ad- 
vises the application of a minute drop of tincture of iodine after 
incision, thereby setting up inflammation with the view of de- 
stroying the gland. Hardaway recommends electrolysis, with 
the needle and battery, as in the operation for the permanent 
removal of hair. 

SEBACEOUS CYST. 

Syn., Encysted Tumor ; Follicular Tumor ; Sebaceous Tumor ; Atheroma ; 
Steatoma; Wen. 

Sebaceous cyst appears as a variously-sized, firm or soft, 
roundish, more or less prominent tumor having its seat in 
the skin or subcutaneous connective tissue. 

Symptoms. — The skin covering sebaceous cysts is normal in 
color, or whitish, owiug to extreme distention. The tumors may 
occur singly or in great numbers. In size they vary from a pea 
to a walnut and larger; in shape they are rounded, and either 
flattened or semiglobular. In consistence they are either hard, or, 
as is more commonly the case, soft and doughy. They are, as a 
rule, freely movable, and are unattended by pain. The scalp, face, 
back, and scrotum are the favorite localities for the development 
of these formations. Their course is slow ; not infrequently they 
exist for years without giving rise to inconvenience. At times, 
when excessively distended, they break down and ulcerate. 

Two kinds of tumors may be distinguished : one in which the 
duct is open, the other in which it is closed. Where the duct re- 
mains open, the tumor is usually flat in form, tending to extend, 
itself laterally rather than above the level of the skin; this variety 
is most frequently encountered on the neck and back. Where, 
on the other hand, the duct has become obliterated, constituting 
the true encysted tumor, the formation assumes a semiglobular or 
even a globular form, projecting itself prominently beyond the 



1 3 1 DISORDERS OF SECRETION. 

level of the skinj it is common upon the scalp, and occurring 
here is usually devoid of hair. 

Pathology. — The contents of sebaceous tumors vary. The mass 
is ordinarily firmly encysted, and may be either soft and cheesy or 
hard and friable in consistence. It may be yellowish or whitish 
in color. It is often fetid in odor. Occasionally the contents are 
fluid in character. The mass is composed of sebum, epidermic 
cells, crystals of cholesterine, and at times hairs. In structure 
these tumors arc to be regarded as enormously distended sebaceous 
glands and ducts, whose walls have become so greatly thickened 
and hypertrophied by the continual pressure exerted upon them 
as to form a thick, tough sac, or cyst. 

Diagnosis. — No difficulty exists in the diagnosis; they may, 
however, be confounded with fatty tumors, and with the tumors 
of epithelial molluscum. 

Treatment. — The treatment is excision. The cyst should always 
be carefully and thoroughly dissected out, without which precau- 
tion the disease is likely to be reproduced. Injection with certain 
irritating fluids, as, for example^ tincture of iodine, may also be 
practised with success. 

HYPERIDROSIS. 

Syn., Idrosis; Hydrosis ; Polyidrosis; Sudatoria; Ephidrosis ; Excessive 
Sweating. 

Hyperidrosis is a functional disorder op the sweat glands 
consisting in an increased flow of sweat. 

Symptoms. — It may vary greatly as to quantity, from slightly in 
excess of health to the pouring forth of large amounts. The con- 
dition may exist as an acute or as a chronic one. It may be either 
universal, involving the whole body, or local, attacking certain 
regions, as, for example, the palms and soles. The temperature in 
some cases is markedly increased, while in others it is lowered. 

Universal or general sweating is observed in the course of a 
number of diseases, as, for instance, in pneumonia, tuberculosis, 
rheumatism, and various febrile maladies. It also occurs in those 
who arc otherwise in health, especially when exposed to the influ- 
ence of a high temperature. In a majority of these cases, however, 
ii i- scarcely to be considered in the light of a disease. 

Local hyperidrosis is always a disagreeable and annoying dis- 



HYPERIDROSIS. 135 

order. It may occur upon any portion of the body, but is more 
commonly encountered about the palms, soles, axillae, and genitalia. 
It may or may not be symmetrical. It may be constant, or, as is 
more usually the case, intermittent or paroxysmal. Sometimes it 
is periodical, as in the case of Yandell,* in which the flow recurred 
daily at the same hour. Numerous cases of unilateral sweating 
are on record, the affection occupying one side of the body, one side 
of the forehead, a cheek, an arm, a leg, and other single regions. 
Sometimes small areas, occasionally in the median line, are the 
seat of the disorder. The subject of the anomalies of perspiration 
has recently received attention from Dr. J. H. Pooley,f who has 
collected the records of many curious cases. Wilson| relates the 
singular case of one who perspired freely on one side of his face 
and on the opposite side of his chest at the same time, while the 
rest of the body remained dry. Interesting instances of localized 
sweating are also reported by Dr. J. J. Caldwell, § in an article 
entitled Neuroses of the Pneumogastric and Sympathetic Nerves. 
A case is mentioned of a child who, when nursing at the breast, 
sweated at the knees. Sometimes sweating follows an irritation 
reflexly. Brown-Sequard in his own person finds that when 
he excites the nerves of taste, as by chocolate, in less than five 
minutes a very abundant secretion of sweat ensues on the lips, 
nose, and forehead. || 

The palms, soles, and genitalia are the parts usually attacked. 
The sweat maybe moderately copious or excessive; at times the 
quantity poured out is so profuse as to keep the parts in a state of 
maceration. Upon the palms and soles the secretion is continually 
oozing out in drops, frequently in such quantity as to be dripping 
wet. From the palms it may be so profuse that the fluid will 
accumulate in the hollow of the hand until it runs over the edge. 
The skin cannot be kept dry, becoming wet again in a few minutes 
after having been dried. Upon wiping off the perspiration it is ob- 
served to be of a whitish or yellowish color, and to have a soggy 
appearance. It is ordinarily seen to come from the whole surface. 

* Trans. Iowa State Med. Soc, 1880. (Article by Dr. Lothrop.) 

f Ohio Med. Recorder, 1880. 

J Lectures on Dermatology, London, 1878. 

g Virginia Med. Monthly, Oct. 1878. 

|| Jour, de la Physiologie, t. ii. p. 450. 



136 DISORDERS OF SECRETION. 

The flow is usually :i Bteady one, although it is influenced by the 
general condition, the Btate of the nervous system, and the sur- 
rounding temperature. Upon the soles the affection is even more 
distressing than on the palms, for the socks and shoes become 
saturated with moisture. The maceration of the epidermis, to- 
gether with the secretion about the toes, sometimes gives rise to a 
disagreeable odor, which in spite of frequent washing is difficult 
to remove. The epidermis becomes soaked and macerated, peels 
off, and leave- the tender skin exposed. The pain attending walk- 
ing when in this condition is often severe, and patients at times 
are obliged to remain off their feet. The genital organs are also 
frequently the seat of the disease, particularly in men. The scro- 
tum and perineum are commonly attacked, the symptoms being 
similar to those just mentioned in connection with the palms and 

sole-. 

The disorder may continue for a short time only or it may last 
for years; sometimes it is extremely obstinate. More or less 
hyperemia and erythema-intertrigo may accompany it, especially 
when it occurs about surfaces that naturally come in contact, as 
the genital organs, nates, fingers, and toes. In certain cases it is 
almost invariably aggravated by directing the attention of the 
patient to the subject or by examining the part, showing the dis- 
ease to be largely under the control of the nervous system. Some- 
times it is accompanied by disagreeable sensations, as pricking, 
tingling, or a sense of fulness of the skin. 

Etiology. — The causes are in many instan&es not to be deter- 
mined. It affects the cleanly as well as the uncleanly, and females 
as well as males. In its morbidly exaggerated form Wilson is of 
the opinion that it is commoner in the male than in the female 
sex. Occasionally the tendency is inherited. The same observer 
cites a family of seven children, three males and four females, in 
which all the males suffered from the disease, whilst the females 
escaped. It is, moreover, met with in the young as well as in the 
old, and in the healthy as well as in the feeble. There can be no 
doubt, however, that disturbance of the nervous system, debility, 
and faulty innervation play an important part in its causation, 
this origin being frequently recognized in clinical experience. 
Malaria may also be cited as a cause. Functional or organic 
disease of the internal organs, as the heart and lungs, may give 



HYPERIDEOSIS. 137 

rise to some forms of the disease. Excessive and sometimes 
otherwise abnormal perspiration may also be caused by injuries 
to the nerves, as has been shown by Pooley.* The complaint 
is aggravated by high temperature, and is consequently generally 
worse in summer than in winter. It may be increased by physical 
or mental excitement or stimulus. 

Pathology. — The affection is a purely functional one, consisting 
in an abnormal secretion of the sudoriparous glands, over which 
the vaso-motor system doubtless has control. The secretion usually 
differs chemically in no way from normal sweat. Sometimes the 
amount of sweat discharged in a given time is very large. 

Diagnosis. — This is never attended with any difficulty; at the 
same time it is of importance to distinguish hyperidrosis from 
other disorders of the sudoriparous glands which are accompanied 
by increased secretion and inflammation, as, for instance, prickly 
heat. Oily seborrhoea can scarcely be mistaken for hyperidrosis. 

Treatment. — If there be debility, a general tonic treatment 
should be ordered. Iron, strychnine, quinine, and the mineral 
acids, especially aromatic sulphuric acid, in ten or twenty drop 
doses twice daily, will be found useful. The condition of the 
nervous system is to be carefully investigated. Belladonna and 
atropia are among our most valuable remedies. Atropia may also 
be used hypodermically in doses of from one-hundredth to one- 
fiftieth of a grain. Pilocarpin has been found of service, accord- 
ing to Ringer and Bury.f Ergot has been employed with benefit. 
Faradization has likewise been used with success in some cases. 

Local treatment is of great value in all forms of the disease. 
Water in the form of a bath, unless medicated, is, as a rule, to 
be employed as seldom as possible. Occasionally, however, hot 
water, as hot as it can be borne, is of service. The parts should 
be cleansed and immediately dried. Various dusting powders, as 
starch, lycopodium, magnesia, oxide of zinc, oleate of zinc, and 
talc, or the same medicated, as with salicylic acid, from five grains 
to half a drachm to the ounce, may be used. A formula much 
employed in the German army consists of salicylic acid, three 
parts; talc, seven parts; and starch, ninety parts. They should 



* Ohio Med. Recorder, Sept. 1880. 
f Practitioner, Dec. 1876, p. 401. 



138 DISOBDEBS OF SECRETION. 

always be removed as fast as they become moist and caked. Lo- 
tions containing alcohol and astringents will be found serviceable. 
Tannic acid, two or three drachms to the pint, may be referred 
to. Various other astringents, such as sulphate of zinc, one or 
two drachms t<> the pint of water, and alum, of like strength, 
may be employed ; also salt baths. Acetate of lead may also be 
mentioned, in the strength of a drachm to the pint, with the ad- 
dition of an ounce each of acetic acid and alcohol. Tincture of 
belladonna, diluted or of full strength, is perhaps our most valu- 
able remedy. It often succeeds when others fail. Care should be 
observed in its use, with a view to its toxic effects. Dilute am- 
monia water, and acetic acid, diluted, have been found serviceable. 
Weak solutions of chloral, permanganate of potash, and salicylic 
acid have also been employed with success. In hyperidrosis of 
the palms and soles the following ointment, esteemed by Wilson, 
may be prescribed, the parts being first well washed with carbolic 
acid or juniper-tar soap. 

B Ungt. Picis Liquid*, 

Ungt. Sulphuris, aa, 5i. 
M. Ft. ungt. 
Sig. To bo spread upon cloths and applied with a bandage. 

For obstinate cases involving the palms or soles, however, the 
treatment about to be described will be found of greatest service.* 
To insure success, it is necessary that its various steps be closely 
followed. The parts are to be cleansed with water and soap, and 
the following ointment applied on pieces of cloth cut to the size 
of the region. Lint smeared with the ointment is also to be 
placed between the toes or fingers, so that every portion of the 
skin may be covered with a layer of the ointment. 

R Emplast. Diachyli, §iv ; 

Olei OlivaB, f iv. 
M. Ft. ungt.f 
Sig. To be used on cloths. 

The cloths are to be changed every twelve hours, when the 



* This method of treatment was first introduced to the profession by Hebra. 
f The plaster to be melted, and the oil added and stirred until a homoge- 
neous mass results. 



ANIDROSIS. 139 

parts are not to be washed, but rubbed dry with lint and a starch 
dusting powder, after which new dressings are again to be applied 
in the same manner. This proceeding is to be continued for from 
one to two weeks. When the disease is upon the soles, the patient 
may walk about in loose shoes. At the expiration of eight or ten 
days the parts are to be rubbed with the dusting powder and the 
dressings discontinued. The powder should be used for several 
weeks longer. Usually the sweating tends to disappear after two 
or three weeks from the beginning of the treatment. A repetition 
of the course, in severe cases, is at times necessary before bringing 
about a complete cure. For slight hyperidrosis some of the stim- 
ulating toilet soaps, containing sulphur, juniper-tar, or carbolic 
acid, may be employed. 

Prognosis. — This should be guarded. Many cases are easily 
relieved, while others are extremely intractable. The state of the 
health, and. the duration and locality of the disease, as well as its 
extent, are all to be considered. Lastly, the ability of the patient 
to follow the treatment must influence the result. 

ANIDROSIS. 

Anidrosis is a functional disorder of the sweat glands 
consisting in a diminished and insufficient secretion of sweat. 

Symptoms. — It is the opposite of hyperidrosis. It occurs in 
the course of certain chronic diseases of the skin, and is particu- 
larly noticeable in ichthyosis; it may also be observed in patches 
of eczema, psoriasis, lepra, and elephantiasis Arabum. It may 
exist as the result of a congenital deficiency of the sweat glandular 
ajDparatus, in which case the person perspires very slightly, and 
perhaps sensibly only under a high temperature. Local anidrosis 
is occasionally noted as a result of injuries to nerves. Fear and 
passion may also s6metimes cause a temporary arrest of the se- 
cretion. 

There are other cases in which the individual ceases at times to 
sweat. In these instances the health is more or less impaired, and 
serious symptoms may arise, especially during the warm weather. 
It is at this season that such cases are apt to come under observa- 
tion. Occurring as an independent disorder it is rare. I recall 
the case of a man— a blacksmith — who suddenly during the hot 
weather ceased sweating. He was, when I saw him, several 



140 DISORDERS OF SECRETION. 

weeks after the difficulty first manifested itself, unable to pursue 
his occupation, and complained greatly of indisposition, headache, 
and other symptoms of distress. 

Treatment. — Every means should be instituted to promote the 
activity of the skin and to restore the function of the glands. 
Hot baths and steam baths are to be recommended. Cold baths 
with frictions may also be of service. Exercise is to be freely 
indulged in, and the general health looked after in every way. 
Sudorific drugs, as jaboraudi and its alkaloid pilocarpin, may also 
be resorted to. 

BR0MIDR0SIS. 

Syn., Osmidrosis ; Odorous Sweat ; Stinking Sweat. 

Bromidrosis is a functional disorder of the sweat glands 
characterized by more or less sweating and an offensive odor. 

Symptoms. — The secretion may be normal or abnormal as regards 
quantity. It may occur either as a universal or as a local disorder. 
When universal, the patient is noted to exhale a peculiar, heavy, 
disgusting odor from the whole surface, which is intensified with 
increased perspiration. It may have a distinctive character, which 
may be likened, for example, to the odor of a goat (odor hircinus), 
of urine (odor urinosus), onions, assafoetida, sulphur, or musk, or it 
may be simply strong-smelling. Peculiar odors are also noted in 
connection with various systemic diseases, as the exanthemata, es- 
pecially smallpox; also with some fevers, as, for example, typhus 
and relapsing fever. Certain foods are said to give rise to peculiar 
odors, as, for instance, a long-continued diet of fish. The odor of 
some drugs is also to be detected in the exhalations from the skin, 
as, for example, sulphur, assafoetida, musk, iodine, etc. Occasion- 
ally a peculiar mousy or musky odor emanates from the skin, 
especially from the axillae, without there being sensible perspira- 
tion. Some persons are always so affected. Wilson* relates the 
case of a man who suffered from a disagreeable odor arising from 
the skin, which, however, was not perceptible to those about him. 
It was not amenable to treatment, but disappeared after an attack 
of pneumonia.f 



* Lectures on Dermatology, London, 1878. 

f Dr. W. A. Hammond (The Odor of the Human Body as developed by 
Certain Affections of the Nervous System, New York Med. Eeeord, vol. xii., 



BROMIDEOSIS. 141 

The local forms are more frequently encountered. Certain re- 
gions of the body, as the axillae, genitalia, perineum, and feet, are 
the usual seats of the disorder. The intensity of the odor varies, 
being at times merely heavy, and in other instances so penetrating 
and offensive as to banish the individual from society. It is usually 
worse in damp or moist weather. Bromidrosis of the feet (bromi- 
drosis pedum) is the most common local form, and constitutes a 
disgusting disease. The disease generally begins in the form of a 
small irregularly-shaped patch on the back part of the sole, with 
a well-defined pinkish margin. It is generally symmetrical. The 
heels become tender, and excoriated or blistered, and walking 
painful. On rising, the soles are often bright red in color and 
shining, becoming through the day whitish and sodden. It is 
encountered in both sexes, and most frequently between the ages 
of twenty and thirty. The emanations here are intensified by the 
perspiratory secretion acting upon the normal sebaceous matter, 
producing a smell particularly foul. According to Hebra, and 
more recently Thin,* the smell is not in the feet but in the cover- 
ings, — in the socks and soles of the shoes. The latter observer 
states that the fluid in which the sole of the sock is soaked teems 
with bacteria (Bacterium foetidum), which acts as an- irritant to the 
skin. Owing to the warmth and moisture which always exist 
about these parts, the scent is exceedingly persistent. The disease 
is similar to hyperidrosis, the main difference being in the quality 
of the secretion. The causes are generally obscure, though in the 
majority of instances connected with the nervous system; emotional 
disturbance, also sexual excitement, are known to be causes in 
certain cases. 

1877, p. 460) records several interesting cases of odorous sweat ; one of a 
young married lady of hysterical disposition, from whom during a paroxysm 
an agreeable odor similar to that of violets, and perceptible at a distance of 
several feet, with marked hyperidrosis, was exhaled only from the left lateral 
half of the anterior wall of the chest. The hyperidrosis as well as the odor 
was relieved by the internal use of salicylate of sodium in five-grain doses. 
In another case the emission of a pineapple odor coincided with an attack of 
chorea; in a third case a pineapple odor was emitted from the skin of the 
head, neck, and chest of a woman whenever she was angry. A fourth case 
was that of a man who emitted the odor of violets during attacks of hypo- 
chondria. 

* Brit. Med. Jour., Sept. 18, 1880, p. 463. See also Proc. Eoyal Soc, No. 
205, 1880. 



142 DISORDERS OF SECRETION. 

Treatment. — The treatment, speaking generally, is the same as 
that recommended for hyperidrosis. At the same time there are 
certain remedies and formulae which are found of special value, 
particularly with reference to bromidrosis of the soles. A solution 
of permanganate of potassium, from one to three grains to the 
ounce of water, used as a wash, will sometimes act happily. A 
saturated solution of boracic acid (about fifteen grains to the ounce) 
is a valuable remedy, having a beneficial effect also on the reddened 
and excoriated skin. Thin advises the employment of cork soles 
for the shoes, and that they be soaked in a solution of boracic acid' 
and dried before being used; and that, moreover, the socks be 
similarly treated. Chloral, from ten to forty grains to the ounce 
of water or of dilute alcohol, may also be recommended. The 
feet should first be bathed in soapsuds. 

Dusting powders are also very useful. They have been referred 
to in considering hyperidrosis. Among the most valuable of these 
are alum and salicylic acid, either alone with starch or in various 
combinations. Bull* speaks of having had success, in an obstinate 
case affecting the axilla;, with oleate of mercury, ten per cent, 
strength, previously sponging with alcohol. In addition to the 
local treatment, in obstinate cases recourse may be had to the inter- 
nal remedies mentioned in considering hyperidrosis. Hypodermic 
injections of pilocarpin have been successfully employed in bromi- 
drosis pedum by Armaingaud,f and without inconvenience to the 
system. 

CHROMIDROSIS. 

Syn., Epliidrosis Discolor; Colored Sweat. 

ClIROMIDROSIS IS A FUNCTIONAL DISORDER OF THE SWEAT GLANDS 
IN WHICH THE FLUID POURED FORTH IS VARIOUSLY COLORED. 

Symptoms. — In this affection the secretion of sweat is usually 
excessive and possesses positive color; it may be bluish, blackish, 
brownish, reddish, greenish, or yellowish. The bluish, blackish, 
and reddish colors are those most frequently encountered. It con- 
sists in an oozing of sweat, more or less profuse, which is observed 
to come directly from the openings of the ducts. The fluid pos- 
sesses the properties of normal sweat and in addition the peculiar 

* Lancet, May 8, 1880. f La Trance Med., 1881, p. 128. 



CHEOMIDEOSIS. 143 

coloring matter. The disease is rare.* It must not be confounded 
with hsematidrosis, where the corpuscular elements of the blood 
are found in the fluid poured out. It occurs generally in women, 
is much more frequent in unmarried than in married women, 
and is not infrequently connected with uterine disorders. It is 
usually associated with a nervous or debilitated condition. I have, 
however, recently observed a case of red chromidrosis in a strong, 
hearty man, where no cause could be assigned. Various regions 
may be attacked, but it has been noted more frequently upon the 
face, chest, abdomen, arms, hand, and feet. The amount of secre- 
tion may be slight or excessive in quantity. As a rule, the flow 
is not constant, but appears suddenly, remains for a short time, 
and then disappears again. It may come and go in this manner 
for a period of weeks or months. It is usually brought on by 
excitement, emotion, or passion, although it may appear without 
any exciting cause. 

Pathology. — The disease is accounted for by an alteration of 
the secretion, caused sometimes by the presence of some abnormal 
coloring matter. Prussian blue, indican, copper, and other simi- 
lar substances have been detected by analysis in the sweat, to 
which the color was doubtless due. 

Treatment. — The treatment is to be directed against the general 
condition of the patient, which will usually be found to be one of 
chlorosis, anaemia, debility, or nervous disturbance. 

Ueidjrosis. — By this term (urinidrosis, sudor urinosus, urinous 
sweat, or sandy sweat) is meant an excretion from the sweat 
glands containing the elements of the urine, especially urea. This 



* Numerous cases are on record which have heen reported from time to 
time and collected, as in the monographs of Le Eoy de Mericourt (Memoire 
sur la Chromidrose, Paris, 1864) and of Hardy (Nouveau Dictionnaire de 
Med. et de Chir. Pratiques, vol. vii., Paris, 1867). A. W. Foot has also made 
valuable contributions to our knowledge of the disease (Dublin Jour, of Med. 
Science, August, 1869, and December, 1873 ; also Irish Hosp. Gaz., February 
16, 1874). Cases are likewise reported by Purdon (Jour, of Cutaneous Med., 
vol. ii. No. 7, and vol. iv. No. 13), and more recently by A. H. Smith (New 
York Med. Jour., July, 1878) and Camuset (Le Mouvement Med., 1879, p. 
419 j see abstract, Phila. Med. Times, November 22, 1879). A collection of 
reported cases will be found in Dr. Pooley's article on the subject in the 
Ohio Med. Recorder, Jan. 1881. 



1 14 DISORDERS OF SECRETION. 

latter has been found in the sweat of healthy persons in varying 
quantities. Under the influence of jaborandi large quantities 
have been excreted, Hardy and l>all* estimating the average 
amount to be seventeen grains for each sweating in the experi- 
ments conducted by them. Occasionally the amount excreted is 
excessive, and is appreciable on the surface of the skin. Such 
cases have been reported by Schottinf and Drasche 7 J in connection 
with cholera, and by Kaup and Jiirgensen,§ Leube,|| Deininger,^[ 
and Taylor,** in diseases of the kidneys. Schottin records three 
cases and Drasche twelve cases out of eight hundred and five 
choleraic patients. It shows itself generally in the formation 
upon the skin, usually of the face and hands, of a colorless or 
whitish, saline, crystalline deposit or coating, which in some cases 
is said to have had the appearance "as though flour had been 
sprinkled over the surface," in others as though the skin " had 
been soaped by a barber," and of a " whitish covering, resembling 
hoar-frost, and sandy to the touch." The deposit is generally 
moderately adherent to the surface, but can be scraped off with 
a knife. Under the microscope, in Taylor's case, it was seen to 
consist of small white, irregularly-shaped masses, with crystalline 
prisms and spiculse projecting from them. In the cases in which 
the details of the examination are given, the deposits were found 
to consist largely of urea, as proved by their solubility in water 
and alcohol, and by their yielding with nitric and oxalic acids 
characteristic crystals of the nitrate and oxalate of urea respectively. 
In the great majority of cases the condition has been preceded 
or accompanied by partial or complete suppression of the renal 
function, and by disease of the kidneys and ursemic poisoning. 

Phosphoridrosis. — Examples of phosphorescent sweat are 
very rarely encountered. Panceri,ft of Florence, records the case 



* Jour, de Therap., 1874. 
f Archiv fur Physiol. Heilkunde, 1851, p. 469. 
J Die epidernische Cholera, Wien, 1860. 
g Deutsches Archiv fur Klin. Med., Bd. vi. p. 55. 
|| Ibid., Bd. vii. p. 1. 1f Ibid., Bd. vii. p. 587. 

** Guy's Hospital Reports, vol. xix., 1874, p. 405. 

•ft La France Med., March 31, 1877. See also Cincinnati Lancet and 
Observer, May, 1877, p. 504. 



SUDAMEN. 145 

of a physician who exhibited this phenomenon after eating of 
phosphorescent fish which had made the patient ill, the perspira- 
tion appearing luminous in the dark. The same condition has 
been observed in miliaria. The evolution of light from the living 
human subject has also been observed in the last stage of phthisis, 
and in other diseases of exhaustion. According to Carpenter,* 
Koster reports a case where the body-linen was rendered luminous 
by the perspiration after any violent exercise.f 

SUDAMEN. 

Syn., Miliaria Crystallina (Hebra). 

SlJDAMEN IS A NON-INFLAMMATORY DISORDER OF THE SWEAT 
GLANDS CHARACTERIZED BY PIN-POINT OR PIN-HEAD SIZED, TRANS- 
LUCENT, WHITISH VESICLES. 

Symptoms. — The vesicles are discrete, but crowded together in 
great numbers, and may exist upon any portion of the body ; they 
have preference, however, for the neck, chest, abdomen, and other 
regions of the trunk. They are somewhat raised above the level 
of the surface, and may be felt as slight elevations. In appearance 
they resemble minute drops of free sweat. They are whitish or 
pearl-colored. They form quickly, and soon assume their definite 
size ; their course is variable. Fresh crops may from time to time 
be developed. The lesions are discrete ; they never run together ; 
their contents do not become puriform ; nor do they rupture. The 
fluid is absorbed, and the covering desiccating forms a thin, delicate 
membrane, which passes away in the form of slight desquamation. 

Etiology. — The cause of sudamina may almost always be found 
in some constitutional or febrile disease. The disorder is of fre- 

* Principles of Human Physiology, Phila., 1876, p. 550. 

f For further information on this subject the reader is referred to Dr. 
Pooley's article, Ohio Med. Kecorder, March, 1881. 

Cases of so-called " galactidrosis," or "milky sweat," are reported in 
earlier literature, which on investigation are found to be expressions of other 
forms of disease. True galactidrosis, therefore, may be said not to exist. In 
many cases lymph was doubtless mistaken for milk. The manifestations in 
lymph-scrotum, as seen in Oriental countries, and of chylous urine, may be 
mentioned as bearing on this subject. Albumen, fat, sugar, and mercury 
and other drugs, are stated to have been found in the sweat. (See Pooley, 
Ohio Med. Eecorder, March, 1881.) 

10 



146 DISORDERS OF SECRETION. 

qucnt occurrence in tuberculosis, typhus and typhoid fevers, acute 
articular rheumatism, and puerperal fever. It is caused by high 
temperature provoking unusual activity of the glands. It is 
common during hot weather, is ordinarily observed in those whose 
Bkins arc delicate, and occurs both in children and in adults. Its 
presence is to be considered as a sign of general debility. 

Pathology. — The affection originates in disturbance of the sweat 
glands. The glands become excited beyond their capacity for 
normal excretion, and, in place of the fluid finding its outlet upon 
the surface, from some cause it collects between the layers of the 
epidermis. It is in this manner that the vesicles are formed, as 
demonstrated by the anatomical researches of Dr. Haight, of 
New York.* 

* Sitzungsberiehte der Kais. Acad., Wien, 1868. 



GLASS II. 

HYPEREMIA— HYPEREMIAS. 

In this class are arranged those disorders which are character- 
ized by the presence simply of an abnormal quantity of blood in 
the vessels supplying the skin. The condition may arise from 
a number of causes, and occasions various appearances upon the 
surface. The hyperemic affections possess the following features. 
Redness of the skin is constant, and is present in all degrees of 
color, from pink or light red to dark red; it disappears upon press- 
ure, but is seen to return instantly. The temperature of the part 
is usually elevated. The seat of the disorder is noted to be in the 
superficial portions of the skin, generally in the papillary layer 
of the corium. The hyperemias occur in a variety of forms or 
patterns, usually without definite shape ; they may be the size of 
a small coin or as large as the palm of the hand and even larger. 
Their course is for the most part acute ; they often last but a few 
hours or days ; in other cases they continue for a longer period. 
Slight itching or burning sensations at times accompany them. 

Hyperemias may be classified into active and passive. Both 
forms may, further, very properly be divided into those which 
are idiopathic, and those which are symptomatic. 

Idiopathic active hyperemias are, in a strict sense, local affec- 
tions. They include those disorders occasioned by the direct ap- 
plication of irritating agencies to the skin. Symptomatic active 
hyperemias are, on the other hand, due to general disturbance of 
the system, which usually has its chief seat in some region of the 
body distant from the skin. 

Idiopathic passive hyperemias are due to external causes; they 
comprise the various so-called lividities of the skin. Mechanical 

147 



148 HYPEREMIAS. 

causes, in the form of severe or continued pressure upon the skin ; 
direct obstruction to the circulation, produced by bandages, articles 
of dress, etc., and cold, may be referred to as the most frequent 
sources of this kind of hyperaemia. 

Symptomatic passive hyperaemia occurs in those cases where 
there is some imperfection in the function either of the circulation 
or of the respiration. 'It manifests itself by a more or less general 
bluish or purplish discoloration of the skin; as seen, for example, 
in cyanosis. 

EEYTHEMA SIMPLEX. 

Erythema simplex is a hyperjemic disorder characterized 
by redness, occurring in the form op variously sized, dif- 
fused or circumscribed, non-elevated patches. 

Symptoms. — It consists in a more or less congested state of the 
skin, marked by the symptoms which have been already enumer- 
ated as belonging to the hyperemias. The causes which give rise 
to it are numerous, and are, moreover, diverse in their nature; they 
comprise heat, cold, injuries, poisons, irritating substances of all 
kinds, certain systemic diseases, and disorders of internal organs, as 
of the alimentary canal, etc. It may be idiopathic or symptomatic. 

IDIOPATHIC ERYTHEMA. 

Erythema from Caloric. — Under this head are included the 
erythemas occasioned by heat and cold. Both of these agencies, 
at certain temperatures, bring about simple congestion of the 
skin ; carried beyond this point they provoke exudation from the 
vessels, or inflammation. Artificial heat, the rays of the sun, etc., 
are among the well-known and commoner causes of this form of 
erythema. 

Erythema from Traumatism. — Simple erythema may also be 
occasioned by traumatism, as, for example, continued pressure, 
rubbing, etc. It is observed as the result of tightly-fitting gar- 
ment-, bandages, trusses, etc. 

Erythema from Poisons. — Poisons of all kinds play an im- 
portant part in the production of erythema. Many substances, 
both mineral and vegetable, act injuriously upon the skin. A few 
of these, as mustard, sulphur, arnica, various dye-stuffs, acids, and 



ERYTHEMA SIMPLEX. 149 

alkalies, may be mentioned as not infrequently giving rise to 
cutaneous disturbance. 

SYMPTOMATIC ERYTHEMA. 

Here are to be placed all those simple erythemas, or rashes, 
which occur in the course of certain systemic diseases or as the 
result of some general derangement of the economy. They may 
occur upon any portion of the body, commonly upon the trunk. 
A knowledge of these erythemas is extremely necessary, for they 
frequently simulate other more serious affections. Simple ery- 
themas clue to disorders of the internal organs, as the stomach 
and bowels, are of very frequent occurrence in infants and young 
children. They may assume various markings and patterns, and 
maybe either slight or well denned in their expression. At times 
they are persistent ; in other cases they dispose to relapse from 
time to time. Certain general diseases are at times accompanied 
with hyperemia of the skin, which shows itself in the form of 
roundish spots, the size of a pea or finger-nail, to which the term 
Roseola has been given. It denotes simply the peculiar form of 
the erythema, and in no degree indicates the nature of the disease 
which has brought it forth. Thus, roseola is at times employed 
to express one of the first lesions of syphilis upon the skin ; also 
the erythema which is sometimes observed in connection w T ith 
vaccinia or with variola. 

Diagnosis. — From what has been said it is manifest that the 
boundary line between simple erythema and dermatitis — simple 
inflammation of the skin — is frequently ill defined. As stated in 
considering the subject of hyperemia in connection with the gen- 
eral pathology of the skin, it is often difficult to determine exactly 
when exudation commences; clinically, however, usually no trouble 
of this character presents itself, for the subjective symptoms in 
affections attended with exudation are so decided as scarcely to 
permit of doubt concerning the pathological change. 

Treatment. — This must obviously depend upon the nature of 
the erythema, with special reference to the cause. The idiopathic 
erythemata require nothing beyond the removal of the cause, 
which is in all instances sufficiently patent. In cases of persist- 
ent symptomatic erythema, such as are of common occurrence in 
infants, the internal disorder to which the cutaneous manifestation 



150 HYPEREMIAS. 

is due must be Bought for. Loral applications, where they are 
demanded, should be employed as the case under consideration 
may require ; for this purpose the various bland dusting powders, 
Boothing ointments, and those to l>e mentioned in connection with 
erythema intertrigo, may be used. g 

ERYTHEMA INTERTRIGO. 

Erythema intertrigo is a hyper,emic affection character- 
ized BY REDNESS, HEAT, AND AN ABRADED SURFACE WITH MACERA- 
TION OF THE EPIDERMIS. 

Symptoms. — It occurs chiefly in those parts where the natural 
folds of tin- skin come in contact with one another, as about the 
nates, perineum, groins, axillae, and beneath the mammae, and is 
usually produced by the friction of two opposing surfaces. It is 
especially common in fat persons, and in infants whose skins are 
tender. The skin becomes chafed, and feels hot and sore. Per- 
spiration also at times takes place, which acting upon the epidermis 
macerates it, and gives rise to an acrid, mucoid fluid. If the 
process be not speedily arrested at this stage, symptoms of inflam- 
mation may appear. 

The affection usually makes its advent suddenly, and unless 
checked by the removal of the cause soon becomes annoying to 
the patient; properly managed in its early stage, it ordinarily 
pass< - away as rapidly as it came. It may last but a few hours, 
or, on the other hand, it may continue for weeks. Occurring be- 
tween the nates, its common seat, it is often troublesome, and may 
interfere with walking or sitting. It is apt to be more or less 
persisteni in infants; with proper care and treatment, however, it 
rarely causes much annoyance. It is liable to relapse. 

Etiology. — It is for the most part an affection of hot weather, 
although it may occur in winter if sufficient cause be present: 
thus, in infants it is seen at all seasons of the year. It may be 
either idiopathic or symptomatic in its origin. Unusual exercise, 
sedentary habits, sitting for a long time on cushioned seats, exces- 
sive underclothing, and other conditions which occasion more than 
usual warmth of the body, all favor its development. The cause 
is always to be found in an undue amount of heat about the 
part- affected, arising either from friction or from permitting the 



ERYTHEMA INTERTRIGO. 151 

dpposing surfaces exposed to warmth to remain for some time in 
contact with each other. In children, and in those whose skins 
are particularly delicate and sensitive, simple rubbing, as from a 
garment, may be sufficient cause. This is often observed in the 
newly-born. In infants, as in the case of symptomatic simple 
erythema, the cause may not infrequently be found in stomach or 
bowel derangements, worms in the alimentary canal, teething, and 
other general disorders. 

Treatment. — As a rule, little is required beyond ordinary care. 
The parts should be washed with cold water and eastile soap, or 
with bran-water, and dried with a soft rag or towel. The folds 
of the skin are to be separated and kept apart with lint or with a 
piece of linen cloth. Dusting powders constitute the best topical 
remedies ; they may be prepared with starch, together with oxide 
of zinc, talc, and similar substances, in varying proportions, as, 
for example, in the following : 

R Pulv. Oxidi Zinci, gii ; 

Pulv. Amyli, gvi. 
M. — Sig. Dusting powder. 

In cases which prove obstinate I am in the habit of using di- 
luted lotio nigra as an application. Applied once or twice a day, 
followed by the use of some bland powder, as the above, it is an 
efficacious remedy. Dilute alcoholic lotions may also at times 
be employed. Astringent lotions, composed of alum, acetate of 
lead, sulphate of zinc, acetate of zinc, a few grains to the ounce, 
also prove serviceable in rebellious cases. A weak solution of 
corrosive sublimate will also be found useful in some cases. The 
various remedies to be mentioned in considering the treatment of 
acute erythematous eczema may likewise be resorted to. 



CLASS III. 
EXSUDATIONES— INFLAMMATIONS. 

The exudations, or inflammations, constitute by far the largest 
and most important group of the diseases of the skin. They in- 
clude all those affections which are characterized by inflammation. 
Iu this class are to be found urticaria, eczema, psoriasis, acne, and 
a number of other common diseases with which the physician finds 
himself in daily contact. The various affections are exceedingly 
diverse as regards their external form and character, some manifest- 
ing themselves as erythema ; others as papules, vesicles, pustules, 
and blebs, together with their secondary products, scales, crusts, 
etc.; while yet another class appear as diffused, more or less deep- 
seated inflammations, involving not only the skin but also the 
subcutaneous structures. 

The exudations vary extremely as to their course; some are 
acute, and terminate in spontaneous recovery ; while others, the 
majority, incline to become chronic and to continue indefinitely. 
Some are simple and benign in their nature ; others are most dis- 
tressing to the patient, and at times disastrous in their consequences. 
Their causes are manifold ; in many cases they are singularly dif- 
ferent. Their pathological features alone entitle them to be 
grouped into one class; these have been already considered in con- 
nection with the subject of general inflammation. 

ERYTHEMA MULTIFORME. 

Erythema multiforme is an acute inflammatory disease 
characterized by reddish, more or less variegated, macules, 
papules, and tubercles, occurring discretely or in patches of 
various size and shape. 

Symptoms. — The disease is usually marked by the variety of its 
lesions, which manifest themselves either as erythematous patches 
152 



ERYTHEMA MULTIFORME. 153 

or as papules, vesico-papules, and tubercles. When patches 
occur, they are apt to be of the most varied shapes and sizes. 
The peculiarities of configuration which the lesions assume have 
given rise to the terms annulare, iris, and marginatum, in con- 
nection with the disease, according as they happen to represent 
one or another of these forms. When the patch is circular in 
form, fading in the centre as the disease extends to the periphery, 
it is termed erythema annulare. Occasionally a series of 
concentric rings are formed, possessing variegated colors, as red, 
purple, yellow, and blue, the condition being designated ery- 
thema iris. At times the patches, after spreading over a con- 
siderable surface, gradually fade in the centre, and terminate 
with a sharply-defined border, the disease consisting at this stage 
simply of serpentine lines or bands, this form being known as 

ERYTHEMA MARGINATUM. 

In place of an erythematous patch, the disease frequently appears 
in the form of distinct papules and tubercles, which occurrence has 
given rise to the names erythema papulosum and erythema 
tuberculosum. The former of these varieties is that in which 
the affection is commonly encountered. It consists of isolated or 
aggregated flat papules, variable as to size and shape. They are 
bright red, violaceous, bluish or purplish in color; disappear in 
part under pressure, and soon fade, seldom lasting longer than a 
week or a fortnight. Erythema tuberculosum is to be viewed 
simply as an exaggeration of the papular form of the disease. All 
of these varieties are but different forms and stages of one process. 
In a given case it is not rare to see several of these manifestations. 
They frequently run into one another. It is this protean character 
of the lesions that has given rise to the name by which the affection 
is known, — erythema multiforme. 

The course of the disease is an acute one; it may continue for a 
few days or for two or three weeks, at the end of which time it 
disappears spontaneously, leaving, perhaps, slight pigmentation 
and desquamation. During its course new crops of lesions are 
apt to develop, appearing from time to time in the place of those 
which have faded away. 

It attacks certain regions of the body in preference, the backs 
of the hands and feet, and the arms and legs, being the localities 
commonly invaded. The hands and fingers are most frequently 



154 INFLAMMATIONS. 

attacked.* It usually occurs symmetrically. It may also show 
itself about the face, especially the forehead, in the form of macules, 
maculo-papules, and papules, and also upon the trunk. Occasion- 
ally it attacks the mucous membrane. Sometimes it is general, 
involving the whole surface, in which case it is usually erythema- 
tous in form. 

The subjective symptoms are seldom troublesome. As a rule, 
the itching and burning are slight, notwithstanding the angry look 
which the eruption often assumes. Symptoms of general disturb- 
ance may or may not accompany the complaint; not infrequently, 
however, in extensive cases, malaise, headache, rheumatic pains, 
and gastric derangement are present. It is seen for the most part 
in early adult age. 

Etiology. — The aifection is somewhat peculiar, in that it very 
often makes its appearance during the spring and. autumn. It is, 
however, also seen at other periods of the year.f The causes are 
for the most part obscure. The papular form, however, is some- 
times called forth by a derangement of the stomach ; in these cases 
it is observed to run a course somewhat similar to that of urticaria. 
It is often accompanied with rheumatism, and in some instances 
bears a resemblance to purpura rheumatica. Lewin considers 
genito-urinary diseases as disposing to call forth the efflorescence. 
It occurs in both sexes, but is more common in the female. 

Pathology. — It must be classed with the exudative affections, 
occupying a position by the side of urticaria, with which it some- 
times possesses certain points in common. LewinJ and others 
regard the process as a vaso-motor disturbance. The close rela- 
tionship between it and herpes iris has long been recognized ; the 
latter disease is in reality but an advanced stage of erythema iris. 
Up to the point of vesiculation it is an erythema multiforme, 
while beyond this stage it is called herpes iris. They are, there- 
fore, notwithstanding their usual separation (which rests purely 



* See Plate CC in my Atlas of Skin Diseases. 

f Fur further information upon this and other points of interest relating 
to the disease, see a report by Lipp, Archiv fur Dermatologie und Syphilis, 
vol. iii. p. 1221 ; also an able article by Moriz Kohn (Kaposi), in the same 
journal, vol. iii. p. 381, and communications by Lewin, Berl. Klin. Wochen- 
schr., Nr. 23, 1876, and Charite Annalen, Bd. iii. p. 622. 

1 Berl. Klin. Wochenschr., Nr. 23, 1876. 



ERYTHEMA MULTIFORME. 155 

upon anatomy), one and the same process. The relationship to 
erythema nodosum is likewise close, some cases of this disease 
being clinically merely severe expressions of the affection under 
consideration. In other cases, however, the diseases seem to 
have distinctive points of difference. Of the morbid anatomy of 
the lesions nothing definite, beyond their inflammatory nature, is 
known.* 

Diagnosis. — When the peculiar appearance and acute course of 
the lesions, together with their multiform character, are borne in 
mind, no difficulty should occur in the diagnosis. The absence of 
violent itching or burning sensations will serve to distinguish it 
from urticaria, the affection to which it bears closest resemblance. 
It differs from urticaria, moreover, in that the eruption is usually 
more pronounced in character, is of a more decided color and 
form, is more persistent in its course, and in the absence of wheals. 
From eczema papulosum it is to be distinguished by the absence 
of severe itching, and by the large size of the papules, as well as 
their irregular shape and form. The difference between herpes 
iris and erythema iris being one only of development, they are 
often seen to merge into each other; the diagnosis here would be 
one simply concerning the name. If there were no vesicles pres- 
ent, it would be termed an erythema; while if these had formed, 
the term herpes would be employed. Erythema nodosum is to be 
diagnosed from erythema multiforme by its prominently raised, 
rounded, firm tumors or nodes, which occur for the most part on 
the extremities, and in particular along the line of the tibise. 

Treatment. — In the majority of cases no active treatment is 
called for. The bowels should be opened by a saline laxative, 
which may be repeated from time to time. Full doses of quinine 
may also be administered in the beginniug of the attack. The 
diet should be light, all stimulating articles of food and drink 
being avoided. The local applications should be of the simplest 
character. Lotions of equal parts of alcohol and water, or of 
carbolic acid, a drachm or two to the pint of water, will be found 
useful where there is itching. Dusting powders of starch and 
oxide of zinc, equal parts, are of service in protecting the inflamed 
surface. 

* See the researches of Campana, Yiertelj. fur Derm. u. Syph., 1878, p. 318. 



1 ob* INFLAMMATIONS. 

Prognosis. — The affection runs a spontaneous course towards 

■ iv. With or without treatment, it usually terminates in 

from two to four weeks without leaving any trace of its former 

existence. It is a benign disease. Relapses are liable to recur 

from time t<> time, especially from year to year. 

ERYTHEMA NODOSUM. 

Syn-i Dermatitis Contusiformis ; /•>., Erytheme Noueux. 

Erythema nodosum is an acute inflammatory disease char- 
acterized BY THE FORMATION OF ROUNDED OR OVALISH, VARIOUSLY- 
BIZED, MORE OR LESS ELEVATED REDDISH NODES. 

Symptoms. — The disease is apt to be ushered in with some dis- 
turbance of the system. Later, febrile symptoms may be marked, 
and the temperature high. The nodes make their appearance 
often suddenly, and may exist upon various regions of the body, 
although they have decided preference for the arms and legs, es- 
pecially the latter region over the tibiae. They vary in size from 
a small nut to an egg; are ovalish or rounded in shape; and are 
sometimes prominent and well defined in outline. In color they 
are reddish with a tendency to become bluish or purplish, be- 
coming darker as they grow older. As they disappear they as- 
sume a variegated yellowish, greenish, or bluish tint, resembling 
the coloration of a contusion. When the disease is at its height 
the lesions have a shining, tense look, as though suppuration were 
about to take place ; this process, however, does not occur, for they 
invariably result in absorption. Not infrequently they are more 
or less hemorrhagic in character. To the touch they are usually 
firm, but they become softer as they are about disappearing. In 
number they may vary from one or two to a dozen or more ; they 
may occupy the legs only, or various regions of the body at the 
same time.* As a rule, they do not all appear at once, but come 
out at intervals in the form of crops, accompanied by slight febrile 
symptoms. They are painful and tender on pressure, and are 
usually attended by burning sensations. Sometimes the lymphatic 
vessels are involved. The affection generally terminates in spon- 
taneous recovery, lasting from two to four weeks. Uffelmannf 

* See Plate V in my Atlas of Skin Diseases. 

f Viertelj. fiir Derm. u. Syph., 1874, p. 174; 1877, p. 230. 



ERYTHEMA NODOSUM. 157 

and Oehme,* however, have described an ominous form of the 
disease occurring in tuberculous families, and for the most part 
in young persons. In the autopsies tuberculosis of the internal 
organs was found. Like erythema multiforme, the disease may 
invade the mucous membrane. Both sexes suffer, but it is more 
frequent in females. It commonly occurs in childhood and early 
adult life. 

Etiology. — The causes of the disease are by no means under- 
stood. It is usually met with in weakly individuals. Loss of 
appetite, languor, and other symptoms of malaise may precede the 
outbreak. Rheumatic pains are also generally present, both before 
and during the attack. Digestive derangements, as well as other 
functional disturbances, are also sometimes noted. Like erythema 
multiforme, to which disease it is allied, it often shows itself in 
the spring. It is a comparatively rare disease. According to 
the statistics of the American Dermatological Association, 27 cases 
out of 16,863 cases of skin disease are reported. It is, however, 
commoner than these figures would indicate. 

Pathology. — Its nature is involved in some uncertainty. It is 
an inflammatory process, very similar in character to the several 
manifestations of erythema multiforme, but severer in type, and 
sometimes possessing certain symptoms which are not encountered 
in this disease. While recognizing, therefore, a relationship to 
erythema multiforme, it may for the present be considered sepa- 
rately. Hebraf appears to think that in some cases at least it is 
essentially an inflammation of the lymphatics, the nodes being 
frequently observed seated on the course of these vessels. But, as 
Hebra states, this view does not hold good for all cases met with. 
Bohn| is of the opinion that each tumor is an inflammatory in- 
farction, caused by embolism in the cutaneous vessels. He conse- 
quently regards the affection as being closely allied to purpura 
rheumatica. In some cases the exudation is of a serous character, 
but in other instances it is hemorrhagic. The process varies in 
intensity. 

Diagnosis. — It is not to be mistaken for the result of external 

* Viertelj. fur Derm. u. Sypli., 1878, p. 324. 

f Diseases of the Skin, vol. i. p. 291, New Syd. Soc. translation. London, 
1868. 
X Jahrbuch fur Kinderheilkunde, Heft 4, 1868. 



158 INFLAMMATIONS. 

violence. The swellings at times bear a close resemblance to 
bruises, and may readily be confounded with injuries of this 
kind. The disease also simulates erysipelas, especially if it occur 
about the face, but may be distinguished from it by the presence 
of the nodes or circumscribed in tilt rat ions, and by other symptoms. 
The lesions at times resemble threatening abscesses; but their pre- 
vious history, number, situation, and course will always serve 
to characterize them. They can scarcely be confounded with 
furuncles. The affection may be diagnosed from the papular 
and tubercular varieties of erythema multiforme by the presence 
of the nodes and the deep-seated character of the disease. 

Treatment. — Xo active treatment is called for, inasmuch as the 
complaint ends in spontaneous recovery. The febrile symptoms 
may be combated by such remedies as seem indicated. Symptoms 
of functional derangement should be corrected. The bowels are 
generally constipated, and are best relieved by a saline laxative. 
The alkaline natural mineral waters may be prescribed with advan- 
tage. A simple diet should be ordered, together with such reme- 
dies as may seem proper. In females, the preparations of iron are 
often given with benefit. Quinine in large doses is also useful. 
If the affection be extensively developed upon the lower limbs, 
rest and the recumbent position should always be enjoined. Local 
applications are of little avail; warm fomentations or cold applica- 
tions, or such remedies as would be indicated iu the treatment of 
contusions, are at times useful in affording relief when the parts 
are painful. Strong applications should never be employed. 

Prognosis. — This is generally favorable. The disease seldom 
lasts longer than three or four weeks. Relapses are rare. 



URTICARIA. 

%>?., Nettle-rash; Hives; Fcbris TJrticata ; Germ., Xesselausschlag ; Fr., 
Urticaire. 

Urticaria is ax inflammatory affection characterized by 
the development of wheals of a whitish, pinkish, or reddish 
color, accompanied by stinging, pricking, tingling sensations. 

Symptoms. — The disease shows itself by the sudden formation 
of wheals, of variable size, shape, and color. They vary greatly 
as to size; at times they are no larger than a split pea, while in 



UETICAEIA. 159 

other instances they occupy extensive tracts of the surface ; ordi- 
narily they are small finger-nail or bean sized. They may occur 
as circumscribed, isolated efflorescences, or in the form of patches, 
caused by a number of the lesions having coalesced. All large 
patches are formed in this manner. Wheals likewise vary exceed- 
ingly as to shape; they are usually roundish or oval, but may 
exist in an endless number of forms. Lines, streaks, crescents, 
and irregularly-shaped patches, may all in turn be formed. At 
times the configuration is curious or even grotesque. They are 
observed either as very slight elevations, barely perceptible above 
the level of the skin, or as raised prominences several lines or more 
in height. To the touch they may be soft or firm. In color they 
are whitish, pinkish, or reddish, and at times are variegated or 
streaked. They are commonly surrounded by a more or less 
distinct areola. No trace, as a rule, follows their disappearance. 

The subjective symptoms are burning, tingling, stinging sensa- 
tions, likened to the sting of the nettle. They may be simply annoy- 
ing, or, on the other hand, exceedingly distressing. The patient 
impulsively scratches, which, though it in part relieves the disagree- 
able sensation, always causes more of the efflorescence to appear. 

Urticaria as ordinarily encountered is the most ephemeral of 
cutaneous diseases. Its advent is usually sudden, a few minutes 
not infrequently sufficing for its development; it may remain upon 
the surface for but a few moments, or for an hour or longer. Even 
while the eruption is out, individual wheals are generally extremely 
fugitive in their character, coming and going in a most arbitrary 
maimer. The disease often leaves one portion of the body to show 
itself in a remote part; it may also repeatedly change its location, 
shifting its seat from time to time without apparent cause. All 
regions of the body, including the scalp and the mucous membrane, 
are liable to its attacks ; the whole surface or only a part may be 
invaded. It has no regions of predilection, but is apt to occur upon 
those parts which are subject to pressure or hy perse mia from the 
contact of the clothes. It occurs at all periods of life, and attacks 
both sexes. Children are particularly subject to it. It is ordi- 
narily an acute disorder, lasting but a few hours or days, during 
which time frequent exacerbations may take place. Its duration 
depends entirely upon the presence or the removal of the exciting 
cause. It may also occur as a chronic affection, the relapses taking 



1 60 IN FLAMMATION.-. 

place with such frequency, and extending over so long a period, as 
to warrant the use of the term chronic. 

There are several varieties of urticaria, named according to 
peculiarities in the confirmation of the anatomical lesion, which 
call for particular description. 

Ubticarla PAPULOSA. — This is a variety of the disease which, 
on account of its peculiar character and frequency, calls for special 
remark* Jt is also known as lichen urticatus. Here the 
lesion possesses the form of a papule with the characteristics of a 
wheal. It is observed particularly in young children, and shows 
itself as pin-head or split-pea sized, flat or acuminated papules, 
which appear, as a rule, suddenly, and, after continuing hours or 
day.-?, slowly disappear. They usually occur in a dispersed manner 
over the body, and are rarely seen in great numbers. They are 
attended with intense itching. Owing to the scratching of the 
patient, their apices are usually more or less torn and covered with 
blood crusts. The disease is generally most annoying at night. 
The children in whom this form of urticaria is noted are, as a rule, 
badly cared for and improperly nourished; but it may also occur 
in the upper walks of life. In my experience in Philadelphia 
this form of the disease is by no means common. In London I 
saw at the clinics many such case-. 

Urticaria is of not infrequent occurrence in the course of other 
diseases. It is necessary, therefore, to distinguish those cases in 
which it is the sole disorder and those in which it exists as a com- 
plication or as a secondary affection. It is seen as a complication 
in several diseases, and often plays so active a part as quite to 
overshadow the primary lesion. Purpura is sometimes the seat 
of urticaria, a mixed lesion resulting, half hemorrhage and half 
wheal, whereby the presence of the hemorrhage is often obscured. 
The urticarial clement, however, is observed to be secondary. 
This occurrence has given rise to the term- urticaria HEMOR- 
RHAGICA and PURPURA URTICANS or URTICATA. A disposition 
to the formation of bullae is now and then observed in connection 
with urticaria, producing an eruption partaking of the nature of 
both blebs and wheals. When this occurs, the wheals usually form 
first, but are displaced by blebs, which may assume the character- 
istic- of the bullae of pemphigus. This peculiar and rare combi- 
nation of symptoms has occasioned the term URTICARIA bullosa. 



URTICARIA. 161 

Occasionally large, walnut or even egg sized, firm, more or less 
persistent nodes or tumors are formed, resembling somewhat ex- 
aggerated lesions of erythema nodosum, constituting urticaria 

TUBEROSA.* 

Acute Urticaria. — According to the cause will the disease 
make its appearance in one way or another. It is, however, usually 
ushered in with slight febrile symptoms, accompanied by languor, 
headache, depression, gastric derangement, furred tongue, and 
other signs of systemic disturbance. The efflorescence appears 
suddenly, so that in an hour's time the whole body may be more 
or less invaded. In other cases only a portion of the body, as the 
face, the trunk, or the limbs, is involved. The wheals are remark- 
able for their capricious nature. They appear and disappear many 
times in the course of the attack, but do not, in preference, return 
upon the old site. About the head they have a tendency to show 
themselves upon the forehead, ears, and nose, producing consid- 
erable swelling and disfigurement. They usually occur isolated 
here, and do not incline to run together to the same extent as 
upon the trunk; in the latter region large, solid patches of wheals, 
the size of the palm or even much larger, are not uncommon. The 
burning and stinging sensations are now intense and almost intol- 
erable. In a variable time, from an hour to a day, the symptoms 
begin to subside; new wheals cease to appear, and the efflorescence 
by degrees fades away until no traces of it remain. The termi- 
nation of the attack is greatly influenced by the removal of the 
exciting cause, as well as by active treatment. Relapses may take 
place. 

Chronic Urticaria. — Here the condition, viewed as a whole, 
is of a chronic nature, and continues for months or years, or, in- 
deed, as long as the cause exists. The individual wheals incline 
to come and go in the same evanescent manner as in the acute 
form, but the patient is rarely entirely free from them. ~No sooner 
has one crop disappeared than another starts up, the skin some- 
times being in an almost constant state of efflorescence. In other 

* This form of the disease was first described by Milton in 1856, and later 
in his work on Diseases of the Skin. London, 1872. In a monograph, with 
the title Giant Urticaria, the same author gives two additional cases, accom- 
panied with a colored portrait. London, 1878. Juler has also reported a case. 
Cincinnati Lancet and Observer, January, 1878. 
11 



162 INFLAMMATIONS. 

cases the eruption is intermittent. At times the wheals are per- 
sistent, and last for hours or longer. The symptoms of general 
disturbance, so prominent in acute urticaria, are usually wanting, 
the individual often seeming to enjoy average general health. 

Etiology. — The causes of urticaria are numerous and of a very 
diverse nature. Certain external irritants and poisons tothe skin 
are capable of producing it in a marked degree : thus, the stinging 
nettle, jelly-fish, caterpillars, fleas, bed-bugs, and mosquitoes are 
not infrequent causes. ,The more sensitive the skin the greater 
will be the disturbance when such agents are brought into contact 
with it. Among the internal causes, gastric and intestinal derange- 
ments are by far the most common ; they may be looked upon as 
productive of the majority of acute urticarias. Thus, an over- 
loaded stomach, excess in wine, or highly-seasoned food, may oc- 
casion an attack ; while certain articles of food, as fish, oysters, 
clams, crabs, lobsters, pork, — especially sausage, — oatmeal, mush- 
rooms, raspberries, and strawberries, are all known to play a con- 
spicuous part in calling forth the affection. A number of medicinal 
substances, taken internally, may likewise occasion an urticarial 
form of disease ; of these, copaiba, cubebs, turpentine, valerian, 
chloral, salicylic acid, salicylate of soda, iodide of potassium, and 
quinine may be mentioned.* It will be understood that in cases 
in which the eruption is produced by the ingestion of any of the 
above enumerated articles, a more or less pronounced idiosyncrasy 
exists. Any irritation in the bowel may give rise to the affection, 
as, for example, intestinal worms, especially in children. Sudden 
emotion or unusual excitement, in some individuals, may be suffi- 
cient to bring it out. In females, menstrual and uterine difficulties, 
pregnancy, and lactation, are sometimes accompanied by urticaria. 
Organic disease of the uterus may also give rise to the affection. 
Malaria may likewise be viewed as one of the causes of chronic 
urticaria. The disease is intimately associated with the nervous 
system. It is often noted in connection with various nervous 
disorders, as spinal irritation, neuralgia, and asthma, and with 
albuminuria. There is also at times a close relationship between 
it and certain general diseases, as purpura and rheumatism. The 
causes of chronic urticaria are usually obscure ; not infrequently 

* See Dermatitis Medicamentosa. 



UETICAEIA. 163 

they may be found in spinal irritation or in organic disease of 
certain organs, as, for example, the uterus or kidney. Sometimes 
the causes are so slight as to be scarcely reconcilable with the 
amount of local disorder. Mode of life, habit, exercise, change 
of air, are all known to exert an influence over the affection. 

Pathology. — Upon close examination, a wheal is seen to be a 
more or less firm elevation, consisting of a circumscribed collection 
of semi-fluid material which has been suddenly exuded into the 
upper layers of the skin. The process is an acute, inflammatory 
one, and has its seat, for the most part, in the papillary layer. 
Neumann* excised and examined with the microscope wheals 
which had been excited by the sting of the nettle upon rabbits. 
The condition found was that of marked oedema of the tissues, 
with a diminution in the supply of blood. Vidalf found in sec- 
tions of skin affected with urticaria the superficial and deep vessels 
of the corium dilated and filled with blood, without alteration of 
the vascular walls. Both the bloodvessels and the lymphatics 
were surrounded by a large number of leucocytes, which were 
also found throughout the whole thickness of the corium, and in 
fewer numbers between the deeper cells of the epidermis. The 
circulation in a wheal is always seriously interfered with. The 
blood is driven from the centre to the periphery, producing the 
characteristic whitish apex and red areola. What part the nerves, 
and what part the muscular fibres of the skin, take in the produc- 
tion of wheals cannot be definitely stated. There can be no doubt, 
however, that the nerves play a very important part in their for- 
mation, and it is probable that the vaso-motor system is concerned 
in their production. The wheals of urticaria papulosa are pecu- 
liar, consisting primarily of a wheal, which induces subsequently 
a deposit of plastic material. Eulenburg regards the disease as 
an angioneurosis. 

Diagnosis. — When the nature of the anatomical lesion is called 
to mind, no difficulty should arise in distinguishing urticaria from 
other affections. Moreover, the peculiar sensations of pricking, 
burning, and stinging, together with the sudden appearance of the 
efflorescence, are characteristic. Its presence as a complication 

* Hand-Book of Skin Diseases, p. 135. Amer. ed., New York, 1872. 
f Annales de Derm, et de Syph., 2me ser., vol. i. No. 3. 



164 INFLAMMATIONS. 

with other diseases may sometimes lead to confusion in the diag- 
nosis ; but in these cases it is to be remembered that it is only a 
secondary production or complication, and consequently of minor 
importance. Erythema papillosum and tuberculosum may be con- 
founded with urticaria ; but they can generally be diagnosed by 
the absence of marked itching. In erythema there are, moreover, 
no wheals, but papules, which possess a different history. Ery- 
thema nodosum bears some resemblance in appearance to the 
tuberose form of urticaria ; but the tumors in erythema are 
usually firmer and more persistent, and, as a rule, are unattended 
with itching. Urticaria should not be mistaken for erysipelas, an 
error which might occur when it is extensively developed over 
the face. When the disease is disappearing, the more or less pig- 
mented lesions may resemble syphilis. 

Treatment. — The first point in the management of a case of 
urticaria is the thorough investigation of the cause which has 
given rise to the attack. In the greater number of cases this may 
be detected, and will be found to consist in some of the disorders 
referred to in speaking of the etiology. To remove or relieve 
these, is the work to be at once taken in hand. When the disease 
is acute and due to gastric disturbance, the treatment is to be reg- 
ulated somewhat by peculiarities of the individual, and also by the 
severity of the attack. The articles of food which the patient has 
been partaking of should be rigidly inquired into; their quality, 
as to freshness, should also be made a matter of scrutiny. In 
severe cases an emetic of sulphate of zinc, ipecacuanha, or mustard 
may be administered, especially if food is still in the stomach. 
The bowels should be evacuated at once, and for this purpose one 
of the saline purgatives, such as sulphate of magnesium or Rochelle 
salt, will be found useful. Free movement from the bowels should 
in every case be obtained as soon as possible. The repeated use of 
mild aperients, moreover, should be continued until recovery has 
taken place. The diet should be of the simplest kind, with the 
avoidance of all stimulating food and drink. Other cases, not 
caused by any discernible intestinal derangement, may often in like 
manner at first be treated advantageously by saline draughts, after 
which the mineral acids or other remedies, and a strict dietary 
regimen, may be prescribed. But the treatment for a given case 
cannot be determined until its nature and cause have been inves- 



UETICAEIA. 165 

tigated. Where there is a disposition to acidity of the stomach, a 
condition of frequent occurrence, alkaline preparations are in- 
valuable. Bicarbonate of sodium in five or ten grain doses, often 
repeated, lime-water, liquor potassa? in small doses, and other 
similar remedies may be employed. Subnitrate of bismuth, com- 
bined with small doses of calomel and opium, is likewise useful in 
allaying the irritability of stomach which sometimes follows acute 
urticaria. The alkaline mineral waters are often refreshing and 
agreeable to the patient. 

In chronic urticaria the bowels should be regulated by means 
of laxatives, preferably saline aperients. The food should be 
nourishing but plain. Attention should be directed to the state 
of the general health. Inasmuch as the causes are often exceed- 
ingly diverse in their nature, and are in many instances obscure, 
each case will require special study. The cause will frequently be 
found to be apparently insignificant, and altogether out of propor- 
tion to the amount of cutaneous disturbance. Whatever the de- 
rangement, no matter how slight, it should at once be remedied, 
if possible. In many cases diuretics are indicated. The acetate 
of potassium in twenty or thirty grain doses, well diluted, may be 
mentioned, also the Poland Spring water (of Maine), as a ser- 
viceable remedy. The natural alkaline waters, as, for example, 
those of Vichy, Carlsbad, and Saratoga (Saratoga Vichy Spouting 
Spring), may at times be used. If gouty symptoms are present, 
they must be encountered by the use of alkalies, colchicum, or 
other means adapted to the requirements of the case. Quinine 
often proves a valuable remedy, not only in cases bearing an inter- 
mittent type, but also in other instances. It should be given in 
full doses, once (at night) or twice in the twenty-four hours. Sali- 
cylate of sodium is well spoken of by Pietrzycki* in cases where 
quinine is indicated but fails, in twenty grain doses thrice daily. 
Pilocarpin is favorably mentioned by Pick,f of Prague, who reports 
cures. Atropia has been recommended by Schwimmer,| and also 
by Fraenkel.§ Small doses of the tincture of belladonna repeated 
every two or three hours until the system is impressed will also be 

* Quoted in London Med. Record, Nov. 15, 1879. 
f Quoted in Phila. Med. Times, vol. x. p. 452. 
% Viertelj. fur Derm, und Syph., 1879, Heft 1, p. 134. 
§ Quoted in Phila. Med. Times, vol. ix. p. 352. 



166 INFLAMMATIONS. 

found useful. Copaiba has been successfully employed in some 
cases; likewise chloride of ammonium, in ten or twenty grain 
doses, a remedy of value to which my attention was directed .by 
Dr. Trent, of Brooklyn. The sulphite and hyposulphite of sodium 
may also be referred to as remedies worthy of trial in obstinate 
cases. Arsenic is of undoubted service at times when other reme- 
dies fail, and is well spoken of by Wilson, Milton, Hardy, and 
others. Bromide of potassium, chloral, and other sedatives will be 
found useful to calm the nervous system, which is often much dis- 
turbed by long suffering. According to McCall Anderson, in some 
cases, where the disease is persistent and due to no appreciable 
cause, bromide of potassium in full doses may be given with the 
hope of permanent relief. Change of climate sometimes proves 
of benefit when all other means have failed. 

Local treatment is of great importance. The burning and sting- 
ing sensations peculiar to this affection are generally so distressing 
as to call for the most prompt and energetic external remedies. 
The patient should be divested of all irritating underclothing. 
The* bed-coverings at night should be light, and the sleeping 
apartment kept cool. Baths and lotions constitute the most de- 
sirable method of applying remedies. They may be prepared with 
various substances, and may be used either warm or cold, as may 
seem to afford the most relief. 

As the disease is apt to be rebellious to treatment, I shall refer 
to a number of remedies, for experience teaches that where one 
fails another may prove serviceable. Sponging the parts with 
vinegar and water at times affords ease. Salt water baths may 
also be used with good result in some cases. One of the best 
remedies is alcohol, in one form or another, as, for example, brandy 
or whisky. It may be applied as a lotion, either diluted or in full 
strength, and will in the majority of cases be found to give decided 
relief. Alkaline baths, made with the carbonates of sodium and 
potassium, often afford relief. For an ordinary tub, containing 
about thirty gallons of water, three or four ounces each of the 
carbonate of sodium and bicarbonate of potassium constitute the 
average strength. A handful of starch, boiled in a quart of water, 
may be added to the bath with advantage. Starch, gelatine, or 
bran baths, prepared in the same manner indicated, are also ser- 



URTICARIA. 167 

viceable. Sulphuret of potassium, from one to two ounces to the 
bath, may at times be employed with good result. Acid baths, 
containing hydrochloric and nitric acids, half an ounce to thirty 
gallons of water, are also recommended. Carbolic acid with water, 
from one to four drachms to the pint, may be employed with 
excellent result ; I frequently employ the following : 

R Acidi Carbolici, sjiss ; 

Glycerinse, f^ii ; 

Alcoholis, fjviii ; 

Aq. Amygdal. Amar., f^viii. 
M. — Sig. Use as a lotion two or three times daily. 

Thymol, a grain to the ounce, in a mixture similar to the above, 
will likewise be found of value. Benzoic acid with water, a few 
grains to the ounce, or with alcohol, ten to twenty grains to the 
ounce, may be referred to. Benzoic acid and borax, each five or 
ten grains to the ounce of water, may likewise be mentioned. 
Chloral, ten to twenty grains to the ounce ; chloral and camphor, 
equal parts, a drachm to the ounce of ointment ; chloroform ; 
corrosive sublimate, five grains to the pint ; bromide of potassium, 
from four to eight drachms to the pint ; dilute hydrocyanic acid, 
one to three drachms to the pint, may be mentioned as being use- 
ful. Acid lotions, as, for example, of acetic and citric acids ; 
dilute ammonia water; and carbonate of ammonia, ten to twenty 
grains to the ounce, may also be found serviceable. 

Prognosis. — A few days usually suffice for the relief of acute 
urticaria when due to gastric derangement. Relapses in these 
instances are liable to occur whenever the patient is exposed to 
the exciting cause. The chronic variety is of a more serious 
nature, and is generally stubborn in its course. The prognosis 
must vary with the likelihood of the removal of the cause. 

Urticaria Pigmentosa. — Under this name cases of an un- 
usual form of disease have been described possessing features which 
entitle it to consideration in the present connection. It is charac- 
terized by the formation of pinkish, reddish, or yellowish wheals, 
similar to those encountered in ordinary urticaria, which incline 
to persist, and to be succeeded by yellowish, orange, greenish, or 
brownish stains, or pigmented spots. The skin in all cases is 



168 INFLAMMATIONS. 

highly sensitive and irritable, the least excitement occasioning an 
outbreak of the lesions, and intense itching and burning. Attacks 
occur at variable intervals, and the disease is usually chronic, the 
lesions lasting from several days to as many weeks. Where a new 
growth has taken place, the lesions, on the other hand, are perma- 
nent, as in a case under my observation. It is encountered in 
children, and in the reported cases first manifested itself early in 
infancy. It may continue for months or years. It may prove 
fatal. 

. The nature of the disease is obscure. Some observers regard it 
as a peculiar form of urticaria, while others, as Tilbury Fox and 
Thin, maintain that it is distinct from urticaria, and that it is to 
be viewed rather as a new growth.* There are undoubtedly two 
varieties of the disease, one of which is to be viewed as urticaria, 
the other as a new growth. Recognition of this fact will account 
for the discrepancy of writers in the reports of cases. In one 
case that I saw, the new growth development (which clinically 
bore some resemblance to xanthoma tuberosum) was pronounced. 
This is the form of the disease called by Tilbury Fox " xanthelas- 
moidea." In two other cases that have come under my notice the 
urticarial element was pronounced, and the question of a new 
growth could scarcely have presented itself. The disease may 
be mistaken for the erythematous or papular syphiloderm, and 
for xanthoma. Cases have been recorded by Nettleship,f Mor- 
rant Baker,! Tilbury Fox,§ Barlow,|| Sangster,Tf Morrow,** 
Goodhart,ft Mackensie,JJ and Cavafy.§§ 



* Thin examined microscopically the lesions in a case and found the disease 
to consist of a granulation cell-growth, not unlike that of scrofuloderma. 
Trans, of Clin. Soc, vol. ix. 

f Brit. Med. Jour., Sept. 18, 1869. 

% Trans. Lond. Clin. Soc, 1875. 

\ Ibid., 1875. Fox describes the disease under the name of xanthelasmoidea, 
on account of its resemblance to xanthelasma, or xanthoma, and gives a plate 
representing a case in his Atlas of Skin Diseases. 

|| Trans. Lond. Clin. Soc, 1877. 

\ Lancet, May 11, 1878. 

** Arch, of Derm., Jan. 1879. 

ff Med. Times and Gaz., Feb. 1, 1879. 

%X Med. Times and Gaz.,- 1880, vol. i. p. 451. 

\l Lancet, 1880, vol. i. p. 739. 



169 



ECZEMA. 

Syn., Tetter; Germ., Eczem ; Fr., Eczema. 

Eczema is an inflammatory, acute or chronic, non-conta- 
gious DISEASE OF THE SKIN, CHARACTERIZED AT ITS COMMENCEMENT 
BY ERYTHEMA, PAPULES, VESICLES, OR PUSTULES, Otf A COMBINATION 
OF THESE LESIONS, ACCOMPANIED BY MORE OR LESS INFILTRATION 
AND ITCHING, TERMINATING EITHER IN DISCHARGE WITH THE FOR- 
MATION OF CRUSTS OR IN DESQUAMATION. 

Symptoms. — It will be noted that the term eczema is employed 
in a broad sense and is made to include a number of diverse 
lesions. Several of these forms of disease have until recently 
been viewed as distinct affections. With the light of modern pa- 
thology, however, we are now enabled to group them together as 
belonging to one process. As we shall presently see, they are but 
varieties and stages of one disease. Regarding, then, these varied 
manifestations in this manner, their study becomes simplified. In- 
deed, it is only by so interpreting the subject, it seems to me, that 
eczema can be at all comprehended. 

The affection exhibits itself in various lesions. It is eminently 
a protean disease. At one time it starts as an erythema • later, 
perhaps, this erythema becomes a moist, excoriated patch, termi- 
nating finally in a thickened, dry, desquamative surface. At an- 
other time it commences in the form of vesicles or pustules, seated 
upon more or less inflamed bases, with a variable amount of swell- 
ing and heat ; the vesicles soon burst, and there results a red, weep- 
ing surface, pouring forth a liquid, gummy discharge, which quickly 
dries into crusts. The character of this patch may now suddenly 
change, and instead of a weeping, excoriated surface there exists 
a dry, scaly, infiltrated, fissured area of skin, which continues 
until the disease is removed. Or, again, papules may first appear. 
These may remain as such throughout their course or may pass 
into other lesions, or they may be associated sooner or later with 
vesicles. Such is a brief outline of the changes which may, and 
frequently do, take place in eczema. There is no other affection 
of the skin in which the lesions, both primary and secondary, 
undergo so many and so sudden ^ alterations ; not infrequently we 
may observe several varieties of eczema manifesting themselves in 



170 INFLAMMATIONS. 

turn upon the same individual. This subject will be referred to 
more at length in the consideration of the varieties of the disease. 

More or less infiltration of the tissues is present in every case 
of eczema. It is one of the most characteristic features of the 
disease. The exudation, whether fluid or plastic, is generally con- 
siderable, and in the majority of instances is excessive, giving rise 
either to discharge and subsequent crusting or to the deposition 
of plastic material. The presence or absence of discharge, that 
feature which for so long a time was regarded as a sine qua non of 
eczema, will depend entirely upon the lesions in which the process 
manifests itself. In the vesicular and pustular forms, especially 
the former, the amount of fluid exudation is usually great, and is 
followed by thickening as well as crust formation. On the other 
hand, in the erythematous and papular varieties no discharge takes 
place, and consequently no crusts appear. More or less desqua- 
mation, however, is present in these cases, varying in amount 
with the stage of the disease, and also with the locality attacked. 

Itching, in varying degree, is a constant symptom of the affec- 
tion. It varies in intensity from that which is simply annoying 
to that which is almost unendurable. Occasionally, it may be said 
rarely, cases of disease, apparently typical eczema as regards the 
eruption, especially of the hands, are encountered where the patient 
denies itching or other subjective symptom. At times the sen- 
sation is that of burning rather than itching ; in other cases they 
occur together ; more rarely pain is present, which sometimes 
exists as the most prominent symptom, the disease being known 
as neurotic eczema. 

Eczema runs its course either as an acute affection lasting a few 
weeks and then disappearing not to return, or, as is much more 
usually the case, it assumes a chronic state, continuing with more 
or less variation for months, years, or a lifetime. As a rule, it 
inclines to settle in the skin and to remain there for an indefinite 
period. 

It may appear as a limited eruption, in the form of variously 
sized and shaped, single or multiple patches, its usual mode of dis- 
tribution, or it may show itself as a diffused disease, involving 
the greater part or in rare instances even the whole of the body. 
Unless occupying an extensive surface, it is seldom ushered in 
with any symptoms of constitutional disturbance. 



ECZEMA. 171 

The varieties of eczema are named according to the lesions which 
the disease assumes at its commencement. 

Eczema Erythematosum. — The primary lesion here is a 
macule, — an erythematous spot or patch. The course of a typi- 
cal case may be described as follows. The condition first noticed 
is an erythematous state of the skin, usually undefined in outline, 
and commonly fading imperceptibly into the surrounding healthy 
skin. It may be small or large ; it may be the size of a small 
coin, as, for example, upon the nose, or it may be as large as the 
hand or much larger. There may be slight swelling present, 
varying with the locality, and with the amount of surface in- 
vaded. There is no fluid discharge or sign of moisture. Ordi- 
narily, in the course of a few days, the patch is covered with a 
thin film of dry, exfoliating epidermis or scale; at times, through 
excoriation, the mucous layer is exposed. The color of the skin 
is usually pale or bright red ; it also often has a slight yellowish 
tinge, at other times a violaceous hue. It may be uniformly dif- 
fused over the affected part, or, as frequently occurs, it may be 
mottled or in the form of patches or blotches. Upon the face, in 
particular, especially the forehead, considerable variation in color 
is apt to manifest itself; at one time it is pale or bright, at another 
time dull or violaceous. 

The disease may either remain localized to a small area or it 
may invade a large surface. It inclines to spread. The process, 
as a rule, varies in intensity from time to time; it is apt to be better 
one day and worse the next, and better one week than another. 
It may even disappear wholly for a time and then show itself again. 
Its course is variable, and at times even capricious. It may pass 
off completely at the end of a few weeks, or, as is more likely to 
be the case, it may assume a chronic course, attended by consider- 
able thickening of the tissues. It is exceedingly liable to relapse. 
The influence of external heat or of excitement, as a rule, aggra- 
vates the condition. A heavy meal, or indulgence in alcoholic 
drink, is likewise very apt to be followed by an exacerbation. The 
burning and itching sensations are in almost all cases marked, and 
generally constitute prominent symptoms. 

Eczema erythematosum may remain as such until it finally dis- 
appears, or it may undergo various changes, as, for example, into 



172 INFLAMMATIONS. 

attacked often determines the form into which it is likely to pass; 
occurring where two surfaces naturally come into contact, as, for 
example, about the genitalia, eczema intertrigo commonly results. 
This form of the disease is also known as eczema mucosum. In 
the majority of instances, however, it terminates in desquamation, 
becoming eczema squamosum. Vesicles or pustules are rarely seen, 
the patch usually remaining in the erythematous or squamous state 
throughout its duration. It ordinarily shows itself about the 
region of the face,* particularly upon the forehead ; it also occurs 
frequently upon the genitalia. 

Eczema Vesiculosum. — The affection usually appears in the 
following manner. There is a feeling of heat and irritation about 
the part for a short time preceding the eruption ; then a diffused 
or punctate bright redness manifests itself, accompanied by itching 
and burning, which continues to increase until in a short time 
numerous, minute, pin-point to pin-head sized vesicles appear. 
They are either discrete or, as is more often the case, closely packed 
together; frequently they run into one another, becoming confluent, 
and making a patch. They grow more prominent from day to day, 
or even from hour to hour, until soon they become distended with 
a clear or opaque yellowish fluid. The tissues are more or less 
swollen, hot, bright red in color, and the itching usually so intense 
that the patient is unable to resist the impulse to scratch. Where 
the swelling is a marked feature, and the vesiculation compara- 
tively insignificant, the condition is known as eczema cedema- 
tosum, and bears some resemblance to erysipelas. The process is 
now at its height, f and thus far has run a rapid course. But the 
disease does not remain long in this condition ; the vesicles soon 
rupture, either of their own accord or through scratching, the fluid 
spreading itself over the surface and at once drying into yellowish 
honey-like crusts. New crops of vesicles subsequently come out, 
or, on the other hand, the discharge exudes so rapidly from the 
skin that there is no time for vesiculation. The quantity of fluid 
exuded is often very great, at times running off in drops. Through 
maceration of the epidermis, and rubbing and scratching of the 
part, there soon results an excoriated, more or less red, weeping 

* See my Atlas of Skin Diseases, Plate A. 

f This stage of the disease is well portrayed in my Atlas of Skin Diseases, 
Plate T. 



ECZEMA. 173 

surface. The amount of crusting will depend upon circumstances, 
as, for example, the locality involved, exposure to the air, the 
removal or not of old crusts, etc. The disease may continue in 
this state for a few days, when the various symptoms will gradu- 
ally subside; or, on the other hand, they may all become aggra- 
vated, the disease in this event passing into another and more 
lasting stage, which has received the name of eczema rubrum. 

The typical vesicular eczema just described is met with fre- 
quently enough in one stage or another of its course ; more often, 
however, associated with the vesicles we find also papules, papulo- 
vesicles, vesico-pustules, pustules, and other lesions. It is in these 
latter cases, and they are common, that the variable character of 
eczema is most manifest. The lesions are often so multiform, 
indeed, that it becomes a matter of difficulty to determine whether, 
for example, vesicles or pustules predominate. Itching is the most 
prominent subjective symptom ; it is generally intense, and gives 
rise to an irresistible desire to scratch. After the vesicles have been 
opened, and the fluid allowed to escape, the itching subsides some- 
what, and burning sensations are often complained of. With the 
advent of another crop of vesicles the itching returns. 

Vesicular eczema may involve a small surface only, or it may 
occur extensively over various regions of the body. It frequently 
shows itself upon the face, in both children and adults; in the 
former it constitutes the crusta lactea of old writers. It also 
shows itself often about the hands and fingers. The lesions show 
no tendency to group, and occur without regularity of distribution. 
They form about the openings of the hair-follicles and on other 
parts of the skin without preference. 

Eczema Pustulosum. — This variety, called also by some 
writers eczema impetigixosum, is closely allied to the preceding, 
with the difference that the lesions assume the form of pustules 
rather than of vesicles. They are formed in the same manner as 
the vesicles, which have been described. Usually the disease is 
accompanied by less swelling, heat, and itching. The pustules 
are usually considerably larger than the vesicles, and are, as a 
rule, firmer in consistence. They develop as pustules, or, as is 
often observed, they may become pustules from vesicles; again, 
both lesions may exist at the same time, side by side. A strict 
line cannot be drawn between the vesicles and pustules of eczema. 



174 INFLAMMATIONS. 

As in the case of the vesicles, the lesions burst, and are replaced 
by thick, bulky, light or dark greenish-yellow crusts, which may 
cover the skin completely. If the process continue, they may ac- 
cumulate in quantity, causing much disfigurement. They desic- 
cate quickly and become friable, finally falling off or crumbling 
away. Eczema pustulosum shows itself most frequently upon the 
scalp and face;* it is common in these regions in children and 
young people, more especially in the strumous and in those who 
are ill fed and improperly cared for. Upon the scalp it usually 
assumes a stubborn character. The pustules may appear here in 
great numbers, sometimes undermining the whole surface, and 
giving rise to a most distressing form of the disease. 

Eczema Papulosum. — This variety, known formerly as 
LICHEN simplex, is characterized by the appearance of papules 
rather than of vesicles or other lesions. Although long considered 
as a disease distinct from eczema, and termed lichen, it is now rec- 
ognized as one of the varieties of eczema. Its eezematous nature 
was first pointed out by Hebra. It appears in the form of small, 
round or acuminated papules, varying in size from a small to a 
large pin-head. In color they are reddish ; at times bright red, 
in other cases darker or violaceous. They may be either dis- 
crete or confluent, and may occur either in patches or in a dis- 
seminated manner over a considerable surface, without regularity 
of distribution. Ordinarily they begin as papules and continue 
throughout their course as such. At times, however, they com- 
mence as papules and pass on into other lesions, as vesicles; or 
they may be associated with vesicles, both lesions occurring at 
the same time. Thus, in papular eczema, while true papules pre- 
dominate, imperfectly-formed papules, half-developed vesicles, or 
even typical vesicles may appear. It is this clinical fact which 
proves the identity of the process, and that the vesicular and pap- 
ular varieties are but manifestations of one and the same disease. 
Where the papules are overcrowded they are apt to run together 
and form solid patches, which, if they be subjected to violent 
scratching or other irritation, may become abraded and result in 
eczema rubrum. Inasmuch, however, as the lesions are usually 
discrete, this seldom occurs. 

* See Plate Y in my Atlas of Skin Diseases. 



ECZEMA. 175 

The papules are usually persistent; they may continue for some 
time without undergoing marked change, or they may disappear 
and be replaced by others. Where they aggregate in the form of 
patches, infiltration is usually extensive. Papular eczema attacks 
by preference the arms, trunk, and thighs, especially the flexor 
surfaces.* It is rarely observed on the face or on the hands and 
fingers. It may invade a limited region or the greater part of the 
body. It is one of the most obstinate varieties of the disease. 
The subjective symptoms are generally more violent than in the 
other varieties of eczema. The itching is often intolerable. 
Patients almost invariably scratch themselves severely, tearing the 
summits of the papules and causing them to bleed. Small blood 
crusts consequently may almost always be noticed here and there 
over regions which are accessible to the hands. Even the skin 
between the lesions is frequently severely scratched and excoriated. 

Having described the varieties of eczema considered from the 
stand-point of the primary lesions, there remain still certain forms 
of the disease which, although not, strictly speaking, varieties, are 
important phases of the disease, and call for special description. 
The first to which attention will be directed has already been in- 
cidentally referred to under the heads of eczema erythematosum 
and vesiculosum, namely, eczema madid ans, or eczema eubrum. 
This must be regarded rather as a condition, resulting from previous 
morbid action, than as a variety of the disease. It is to be viewed 
as a variety only in a clinical sense. It may result either from 
eczema erythematosum, vesiculosum, pustulosum, or papulosum, as 
already indicated. It is characterized by a more or less reddish, 
weeping surface, accompanied by marked inflammatory symptoms. 
Serum usually exudes freely, and at once forms into crusts; blood 
likewise oozes from the lacerated and exposed corium, which, 
together with the serum, dries into thick, yellowish, greenish, or 
brownish crusts, often completely enveloping the region. f These 
crusts adhere closely and firmly to the part, and, unless detached 
by mechanical means, may remain there indefinitely, the disease 
continuing its course beneath the mass of effete matter. Eczema 
madidans, then, presents two appearances, — as it occurs with its 

* See Plate X in my Atlas of Skin Diseases. 

f See the face of a child, Plate in my Atlas of Skin Diseases. 



176 INFLAMMATIONS. 

crust, and as it exists without this covering.* In the one case the 
skin itself is altogether obscured by a dirty yellowish or brownish 
crust ; in the other the skin presents a bright or violaceous red, 
punctate, wounded surface, deprived in great part of its epider- 
mis, and exuding a scanty or profuse, clear or opaque, syrupy, 
yellowish fluid. Sometimes this is streaked with blood. 

Eczema madidans may occur upon any part of the body. It is 
most commonly seen upon the legs, particularly in elderly people, 
in the form of extensive patches, sometimes occupying the greater 
part or whole surface of the limb.f It is for the most part chronic 
in its nature, not only the skin but the deeper tissues also becom- 
ing more or less involved. Infiltration takes place in a marked 
degree, the skin becoming greatly thickened and hardened, feeling 
at times, in old cases, almost leathery. Eczemas in this condition 
may continue for years, not merely showing no disposition to spon- 
taneous recovery, but, on the contrary, tending steadily to increase 
in their development. The flexures of the joints likewise are often 
the seat of eczema madidans; the groins, and the cleft between the 
nates, are also frequently affected, the condition in these instances 
usually arising out of an eczema erythematosum. 

Another important clinical variety or form of eczema is that 
termed eczema squamosum. It is to be viewed as a stage of one 
or another of the four varieties of eczema; it may follow the ery- 
thematous, vesicular, pustular, or papular manifestations of the 
disease. As already pointed out, it generally succeeds eczema ery- 
thematosum. In other cases it shows itself at the termination of 
the vesicular and pustular varieties, in the form of dry, harsh, 
scaly patches. Papular eczema, when the lesions are confluent, or 
are seated so close together as to constitute a solid patch, may also 
result in squamous eczema; patches of this kind are often met 
with upon the extremities. When typical, it is characterized by 
variously sized and shaped, reddish patches. They are dry, and 
are more or less scaly. At times the scales constitute a prominent 
feature, in other instances they are scanty, the locality attacked 
determining to some extent the amount of desquamation.* Infil- 

* See Plate H H in my Atlas of Skin Diseases. 
f See Plate G G in my Atlas of Skin Diseases. 

J See Plate I in my Atlas of Skin Diseases, representing a typical case of 
squamous eczema of the back of the neck. 



ECZEMA. 177 

tration is always present, and in the majority of cases, where the 
patches have existed for some time, is pronounced. When the skin 
is taken up between the fingers, it is felt to be thickened. This 
feature, of course, exists in all degrees ; it may be slight, or, on 
the other hand, extensive, depending upon peculiarities of the 
case. Squamous eczema may be, and is in many cases, merely an 
ephemeral stage of the disease, showing itself for a short time 
only previous to the disappearance of the affection. The term is 
commonly employed, however, to denote the chronic stage, which 
may continue without notable change for an indefinite period. 

Other lesions are encountered in eczema, as they occur upon one 
part of the body or another, which, having peculiarities of a defined 
character, are worthy of mention. 

Rhagades, or fissures, are observed not infrequently upon those 
regions which, by their natural conformation, are subject to con- 
stant motion. The various joints, particularly of the hands and 
fingers, are usually the seat of fissures or cracks of more or less 
severity; at times they are extensive, deep, bright red in color, 
showing the true skin, and so painful that motion is almost impos- 
sible. They usually occur about the normal furrows of the skin, 
but they may show themselves anywhere. They are produced for 
the most part by motion or strain upon the eezematously diseased 
tissues, which in many individuals incline readily to crack. They 
are found, more or less developed, in the erythematous, vesicular, 
and pustular varieties of eczema, the condition being termed 

ECZEMA FISSUM Or ETMOSUM. 

The so-called " chaps," as they take place about the hands, 
mouth, or other localities, may here be referred to. They are 
fissured lesions, often slight, which are liable to occur and to 
recur in skins which have a disposition to eczema, or in those 
which are abnormally tender. They indicate a debilitated . or 
poorly-nourished skin, and are met with most frequently in 
strumous subjects. They may also be caused by the use of ex- 
ternal irritants, as strong soap, the excessive use of water, acids, 
and similar substances ; and by exposure to cold weather, and to 
hard manual labor. 

In thickened, infiltrated, localized patches of eczema a peculiar 
warty, verrucous condition at times shows itself, the appearance 
being due to an hypertrophied state of the papillae. The condition 
12 



178 INFLAMMATIONS. 

may be very properly called eczema verruoosum or papil- 
lomatosum, as suggested by Wilson ; if simply hard, rather than 
wart-like, eczema sclerosum. The latter form is observed most 
frequently about the hands. 

Eczema Acutum et Chroxicum. — A natural and at the same 
time important and proper division of eczema is that into acute 
and chronic. The line which separates the two conditions is one 
which may usually be drawn by means both of its clinical and of 
its pathological features. The division relates not so much to time 
as to certain pathological changes which occur during the course of 
the disease, and which it is necessary to bear in mind in viewing 
the subject of treatment. Eczema, as a rule, inclines to run a 
chronic course; there are, however, many exceptions, constituting 
examples of typical acute eczema, where the whole process com- 
pletes itself in a brief period. So long as the general inflamma- 
tory symptoms are high, and the secondary changes insignificant, 
the disease may be said to be acute; when, however, the process 
has settled itself into a definite line of action, continually repeat- 
ing itself, accompanied by secondary changes, the disease is to be 
considered as chronic. The terms are also at times applied to the 
length of time which the disease has existed. 

Etiology. — Eczema is by far the commonest of all the diseases 
of the skin. It occurs more frequently in some countries than 
in others. In this country, among 24,980 cases of miscellaneous 
skin diseases collected by the committee of statistics of the Amer- 
ican Dermatological Association, occurring in Boston, New York, 
Philadelphia, Baltimore, Chicago, and St. Louis, there were 8551 
examples of eczema, or 34.23 per cent. In Philadelphia, accord- 
ing to my experience, it constitutes perhaps forty per cent, of the 
entire number of cutaneous diseases. In Boston, according to 
White,* the percentage is almost as great; out of 5000 cases of 
skin disease encountered in the out-patient department of the 
Massachusetts General Hospital, 2242 were eczema. In New 
York, Bulkleyf makes the proportion less,— namely, about one- 



* Bost. Med. and Surg. Jour., Jan. 27, 1876. 

f Amer. Practitioner, May, 1875 ; also, Eczema and its Management, New 
York, 1881. 



ECZEMA. 179 

third of all the cases. Anderson,* in Glasgow, out of 10,000 
cases in hospital practice encountered 2527 examples; while 
Hebra,f in Vienna, out of 29,535 cases met with in thirteen 
years in the General Hospital, records only 2195 cases, or not 
quite eight per cent. But at this hospital children rarely appear, 
— a point that must be taken into consideration. More recent 
reports, however, give 517 cases of eczema among 3217 cases of 
skin diseases, or somewhat over sixteen per cent., which is prob- 
ably nearer the actual proportion. Thus it will be noted that the 
disease is more frequent in this country than abroad. 

It attacks people in all spheres, the rich as well as the poor, and 
may appear at any period of life from infancy to old age. Males 
and females are affected in about like proportion, although ex- 
tended statistics prove it to be somewhat more frequent in males. 
In certain cases it is hereditary, the term being used in the sense 
that a predisposition to its development is handed down from 
parent to child. On the other hand, in the vast majority of cases 
no hereditary taint is to be detected. All temperaments are by no 
means equally liable to the disease; individuals with light hair 
and florid complexion suffer more frequently than those with dark 
hair and skins. There are, moreover, certain persons so peculiarly 
constituted that their skins are ever ready to manifest signs of 
eczema upon the slightest provocation, whether this be in the form 
of internal or of external irritants. For example, it is well known 
that in certain people local irritants invariably tend to bring out 
eczema, while the same kind and amount of irritation upon others 
produce at most a simple dermatitis, which passes away completely 
with the removal of the cause.J In like manner, in these cases, 
internal derangements of various kinds are often sufficient to cause 
eczema to appear, while, as we are well aware, no amount of like 
irritation in another class of persons will occasion the least symp- 
tom of eczema. I would state, then, that there seems to be a 
certain inherent peculiarity of constitution in some, which, under 
favorable circumstances, encourages the appearance of the disease. 

* The Lancet, Nov. 11, 1871. 

f Neumann's Lehrbuch der Hautkrankheiten. Wien, 1876. 

J See an able article discussing this question, entitled "Are eczema and 
psoriasis local diseases of the skin, or are they manifestations of constitutional 
disorders?" by Dr. Bulkley. Trans. Internat. Med. Cong., Phila., 1877. 



180 INFLAMMATIONS. 

The so-called catarrhal nature of the disease has been insisted on 
by some dermatologists, chief among whom Tilbury Fox may 
be mentioned. The not infrequent association of eczema with 
chronic bronchitis and asthma inclines us to the belief that in 
some cases a relationship undoubtedly exists. 

Constitutional Causes. — Here are to be found many condi- 
tions which are capable of giving rise to eczema. They play a 
most important part in the production of the disease, and, having 
called it forth, exert a powerful influence in keeping up the process. 
Chief among the constitutional causes rank the various disorders 
of the digestive tract. Dyspepsia (the term being employed in 
its broadest sense), with its long train of symptoms, is to be re- 
garded as one of the commonest causes. Constipation, irregu- 
larity in the action of the bowels, flatulence, dyspepsia of the 
stomach and intestine, and other similar states, may frequently 
be observed to be the cause of the eruption. Deficient excretion 
through the various emunctories of the body is also to be regarded 
as a cause. In certain individuals the presence of an excess of 
uric acid and urates in the system is sufficient to produce and to 
keep up eczema. The association of gout and rheumatism with 
eczema has long been recognized by observers. Sugar and albu- 
men in the urine, especially the former, are also sometimes met 
with in chronic eczema, especially in elderly persons of sedentary 
habits who partake largely of animal food. Without question, 
the presence of the gouty or rheumatic vice, in some subjects, 
strongly disposes to attacks of eczema.* 

As causes of eczema, certain writers have insisted upon the follow- 
ing — it is to be confessed, somewhat unsatisfactory — explanations. 
Mr. Wilson, for example, considers that it is due to "constitutional 
or general debility," which may present itself as "assimilative 
debility," as " nutritive debility," or as " nervous debility." Other 
observers consider that " perverted innervation" is to be viewed as 
the chief cause; others, again, that it is due to the "strumous or 
scrofulous state." Improper food, either as to quantity or quality, 
also acts as an exciting cause. This remark is applicable in the 



* See interesting articles by Dr. Bulkley " On the relations of the urine to 
diseases of the skin," Arch, of Derm., Oct. 1875, and on the "Gouty state 
in diseases of the skin," Amer. Practitioner, Nov. 1877. 



ECZEMA. 181 

case of both adults and infants, but is especially true concerning 
the latter, where the continued use of unsuitable diet frequently 
leads to serious disturbance of the health and to eczema. In 
certain cases, pregnancy and the period of lactation possess a 
decided influence in calling forth the disease. In the same way, 
all causes which tend to lower the average degree of health may 
serve as generators of eczema. It is in this sense that debility, 
nervous exhaustion, excessive mental or bodily work, and kindred 
states, act with manifest force in producing the disease. Eczema 
is often dependent upon a chlorotic state, the disease clinging 
tenaciously to the patient until the general condition has become 
improved. Various kinds of internal irritation, such as ascarides 
or taenise in the bowel, may also sometimes determine an eczematous 
eruption. 

Dentition may operate as an exciting cause, and may occasion 
the disease to appear in infants who are predisposed to it. It is 
to be viewed in the light of a cause, as in the case of any other 
source of irritation to the constitution. The process, as we know, 
is one which not infrequently creates considerable systemic dis- 
turbance. Vaccination likewise at times calls forth an outbreak of 
eczema, but this occurs, as a rule, only in those who have already 
a tendency to the affection. On the other hand, vaccination may 
act as a therapeutic agent and cure the disease. Injuries to nerves 
and neuralgias may also give rise to eczema. Its relations to 
psoriasis in some cases are curious : thus, we occasionally meet 
with instances where the two diseases coexist ; also where subjects 
are liable to attacks of either disease, showing at one time eczema, 
at another psoriasis;* and, finally, where eczema follows pso- 
riasis.f Eczema is not contagious. It cannot be acquired from 
being in contact with or from handling the discharge, although 
this may be so irritating or acrid as to cause a simple dermatitis 
to be set up. 

Local Causes. — These are numerous, and are worthy of care- 
ful investigation ; they play a conspicuous part in the production 
of many eczemas, and give rise to the so-called artificial eczemas. 



* See an article by Campbell, Arch, of Derm., July, 1877. 
f See Neumann, Allg. Wien. Med. Zeitung, Nrs. 1 und 2, 1877 ; also Vier- 
telj. fur Derm. u. Syph., 1 und 2 Heft, 1877, p. 262. 



182 INFLAMMATIONS. 

They are all cutaneous irritants. The preparations of mercury, 
for example, are capable of giving rise to eczema in those predis- 
posed to the disease, as is seen in the condition termed eczema 
mercueiale, which occasionally results from the excessive em- 
ployment of mercurial frictions. The form of eruption here does 
not differ materially from that provoked by other similar sub- 
stances, as, for instance, croton oil, tincture of arnica, tincture of 
cantharides, mustard, antimonial ointment, sulphur, and turpen- 
tine, all of which may give rise to artificial eczema. Dye-stuffs, 
especially those containing aniline, may also be mentioned as at 
times occasioning the disease. 

The effects resulting from contact with the poison-vine (Rhus 
toxicodendron) and poison-tree (Rhus venenata) are well known, 
and exhibit forcibly the virulent influence which certain vegetable 
substances are capable of exercising when brought into contact 
with sensitive skins. The condition produced by these poisons, 
while generally a simple multiform dermatitis, is sometimes an 
artificial eczema, which may be of an erythematous, vesicular, or 
pustular character. It is well recognized that certain persons are 
always attacked when they come in contact with these plants, 
while others are able to touch and handle them with impunity, 
the skin in the latter cases being altogether insensible to their 
deleterious influence. This observation demonstrates clearly the 
great difference which naturally exists in the degree of sensitive- 
ness of skins, and aids in explaining the whole subject of artificial 
eruptions.* 

Heat and cold likewise have a share in some cases in the pro- 
duction of eczema. The heat of the sun, upon parts exposed for 
some time to its action, may cause an eezematous eruption, which 
is expressed by the term eczema solare. Excessive perspira- 
tion, with elevation of temperature, occurring about the genitalia 
and other localities where the skin inclines to form folds, may also 
occasion abrasion of the epidermis, chafing, and eczema, called 
eczema intertrigo. Eczema may similarly follow the inflam- 
matory disorder of the sweat glands known as miliaria, or prickly 
heat, when this latter affection is prolonged and subjected to ex- 
asperating agencies, as friction, irritants, etc. 

* For further remarks, see Dermatitis. 



ECZEMA. 183 

In connection with this subject reference may be made to the 
influence of the seasons upon eczema. The disease is found" to 
be of much more frequent occurrence in winter than in summer. 
Many examples of chronic eczema recover spontaneously during 
the summer season, only, however, as a rule, to reappear with 
the winter. Sudden changes in the weather, especially from warm 
to cold weather, always aggravate these eczemas ; they are not in- 
frequently observed to be controlled in a remarkable manner by 
the seasons. 

Water may, under certain circumstances, provoke an eczema; 
it is seen at times following the inordinate use of baths, water 
dressings, fomentations, etc. Alkalies, and also acids, in one form 
or another, may also be alluded to as causes ; while strong soaps, 
particularly potash soaps, are exceedingly deleterious to many skins, 
and may give rise to harshness, fissures, and eczema. It is in place 
here to make mention of the injurious effects often resulting from 
the improper use of sapo viridis, or common soft soap. This sub- 
stance is, as we know, a most valuable remedy in the treatment of 
certain varieties and stages of eczema ; but it is also a harsh irri- 
tant, capable of doing much mischief when injudiciously applied 
to the skin. Dermatitis and artificial eczema from its imprudent 
use are not rare. 

Two other important sources of eczema remain to be noticed, 
namely, parasites and scratching. The animal parasites claim par- 
ticular attention, the pediculus and the sarcoptes scabiei being most 
prominent. Pediculi, especially those of the head, give rise to 
much disease upon the scalp, and are to be regarded as the cause 
of a not inconsiderable amount of eczema capitis in children. Of 
a like character is the inflammation of the skin produced by the 
long-continued ravages of the itch mite; the condition here differs 
but slightly from eczema vesiculosum. Lastly, scratching plays 
a significant part in the production of artificial eczema, as seen in 
scabies and in pediculosis. 

Pathology. — In considering the pathology of eczema, it is neces- 
sary to bear in mind that we have a highly inflammatory disease, 
which undergoes many rapid changes during its development. 
We must also remember that we have several varieties of the dis- 
ease, as, for instance, eczema papillosum and eczema vesiculosum, 
each running a somewhat different pathological course. Finally, 



184 INFLAMMATIONS. 

it is important to separate the acute from the chronic stage in an 
investigation of the subject. 

Eczema possesses the following points in connection with its 
pathological anatomy. There is, in the first place, hyperemia or 
congestion of the skin, as shown by the redness which is present. 
The bloodvessels and capillaries are overloaded with blood; this 
may take place uniformly over the surface, as in the case of eczema 
erythematosum, or in points, as in eczema papillosum. The con- 
dition is always particularly marked about the follicles, as may 
readily be seen with the naked eye. The important pathological 
process which occurs in the disease is an exudation, which may be 
either of a fluid or of a plastic quality, or of all grades between 
the two. According as the disease assumes an erythematous, 
papular, vesicular, or pustular form will the changes present one 
picture or another. The anatomical changes which have been 
observed in the course of the disease afford interesting knowledge 
upon the subject. Neumann's* experiment upon the skin of the 
ear of a living rabbit, consisting of the irritation of healthy tissue 
by means of croton oil, shows the changes which take place in 
simple dermatitis, and, in all probability, also in idiopathic vesicu- 
lar eczema. At first a rhythmical contraction of* the vessels took 
place, they being at one moment distended and at the next empty, 
but becoming gradually more and more dilated, until stasis was 
ol .served. The -kin, which in the normal state was transparent, 
became opaque, swollen, and hot, accompanied, after a few lion]-.-, 
by the appearance of numerous vesicles. Forty-eight hours after- 
wards the animal was killed, and the tissue found to be infiltrated 
with serous fluid and filled with a great quantity of cells. 

The changes occurring in the papular and vesicular varieties 
have been carefully investigated by Biesiadecki,f as follows. The 
principal seat of disease is the papillary layer. In circumscribed 
portions of the skin the papillae are somewhat enlarged in breadth 
and in length, and are infiltrated with cells, and a clear, serous 
fluid. The connective-tissue corpuscles of the papillae are re- 
markable for their size and succulence, and are increased in number. 



* Loc. cit., p. 169. 

f Beitrage zur phys. und path. Anat. der Haut. Sitzungsb. dc-r k. Akad. 
"Wien, Bd. lvi. p. 243, 1867. 



ECZEMA. 185 

The presence of a serous fluid in the tissues of the papillae is made 
manifest by the compressed condition of the swollen connective- 
tissue fibres. The rete mucosum is observed to be particularly 
altered over the papilla? affected in this manner. Numerous 
spindle-shaped cells are seen prolonging themselves into the mu- 
cous layer, lying half in the papilla? and half in the deepest cells 
of the rete mucosum. They crowd the cells of the rete apart, 
and reach even to the horny layer. These cells often form a 
dense net- work in the rete between the papilla?, penetrating one 
another in all directions. Within this net- work are found some- 
what swollen epithelial cells, whose protoplasm appears less 
marked. This circumscribed infiltration of the pap'illa? forms 
the papule of eczema. In the further course of this process a 
vesicle may be formed. This is produced by the new formation 
of cells within the papilla?, and the superficial cells of the mucous 
layer swelling up considerably, perhaps rupturing, so that the epi- 
dermis becomes raised. The cells in the middle of the mucous 
layer are more markedly swollen, or they may be indistinct, as if 
containing granular matter, the largest nuclei being scarcely recog- 
nizable. In cases of rapidly-developed eczema the connective- 
tissue cells are found entering the rete in greater numbers, and 
form a dense net-work. With the increased abundance of these 
cells there is at the same time a larger quantity of fluid developed 
in the papilla?, to such an extent at times as to raise the epidermis 
up in the form of bulla?. If the epidermis covering the vesicles 
be removed, the fluid oozes forth upon the surface of the mucous 
layer, constituting moist eczema. 

The fluid which pours forth in vesicular eczema is not to be 
distinguished from ordinary serum ; microscopically it offers no 
peculiarities. It is a clear, yellowish, syrupy fluid, of a sticky 
nature, and, as is well known, has the property of staining and 
stiffening linen. When exposed to the air it rapidly dries and 
forms crusts of a yellowish color. 

The alterations which are found in chronic eczema are of another 
character, and differ somewhat according to the stage of the dis- 
ease. The skin here is subacutely inflamed ; is very much thick- 
ened, hardened, and infiltrated with cells. The papilla? are 
enlarged, often greatly so, and at times may be distinguished with 
the naked eye. The cell infiltration extends throughout the entire 



186 INFLAMMATIONS. 

corium, even into the subcutaneous connective tissue. This infil- 
tration occurs diffusely in the tissue of the corium, and also about 
the vessels. Pigmentation may take place in the deep layers of 
the rete, and in the corium, especially about the vessels. In a 
typical case of chronic eczema of the scrotum, Neumann* found 
the papillae considerally larger than normal, and not only their 
bloodvessels, but also the loops of the lymphatics, elongated, the 
latter being dilated in the form of a flask. Nowhere in the course 
of the lymphatics was there to be found any cell proliferation, 
such as existed about the adventitia of the bloodvessels, although 
the corium was in part displaced by cell infiltration. 

In considering the relation existing between the capillary con- 
gestion and the cell proliferation, Tilbury Foxf.is inclined to the 
view that both cells and vessels play an important and somewhat 
independent part, in obedience to a nerve paresis, and that the 
most important element in the production of the disease is faulty 
innervation. Hebra| has expressed a similar opinion concerning 
impaired innervation, but does nut speak of the influence of nerve 
irritation as causing cell proliferation. He remarks, in seeking an 
explanation of the occurrence of the disease, that, inasmuch as it 
may result from irritants and varicose veins, it is fair to suppose 
that the direct cause is a disturbance of the circulation, especially 
in the capillaries, causing capillary congestion. AVhether this be 
the result of disease of the nerves or of the bloodvessels cannot be 
determined. He further believes that the congestion occasions 
such an excessive exudation of liquor sanguinis that it cannot be 
completely consumed in supplying loss, a certain superfluous quan- 
tity remaining over and infiltrating the cutaneous tissues, especially 
the epidermis. 

Diagnosis. — Eczema being the most important of all the cuta- 
neous diseases, a careful study of the subject of diagnosis becomes 
necessary, — the more so when the variety of the anatomical lesions 
which the process may assume is taken into consideration. No 
other disease appears in such varying forms. At one time an 
erythema, either with or without desquamation, followed, perhaps, 



* Lehrbuch der Hautkrankheiten, p. 217. Wien, 1873. 

f Skin Diseases, p. 173. Amer. ed., New York, 1873. 

% On Diseases of the Skin, vol. ii. p. 140, New Syd. Soc. trans. Lond., 18G8. 



ECZEMA. 187 

by a weeping surface and crusts ; in other cases, vesicles, passing 
rapidly into pustules; again, papules, which, when aggregated, 
may break down into a patch, accompanied by moisture; finally, 
one or all of these primary lesions in the same patient, presenting 
a' complete picture of this wonderfully protean skin manifestation. 
Add to this the secondary changes which always occur, and it will 
be readily perceived how difficult the diagnosis of eczema may 
become. To understand thoroughly the affection, it should be 
viewed as a whole, when it will be noted that it presents certain 
characteristics, some of which are invariably at hand. These may 
be referred to. 

A certain amount of cell infiltration is always present in eczema. 
It may be marked or only slight, according to the severity of 
the process. It may be detected by the thickening of the skin, 
which may be both seen with the eye and felt with the finger. 
Swelling and oedema also exist in all acute eczemas, and often in 
the more chronic cases. The patch is red and congested, the red- 
ness disappearing slowly beneath pressure, and returning in like 
manner. The exudation of fluid or plastic material is a constant 
symptom, and is observed in varying degrees. 

In the majority of cases, fluid exudation, or moisture, has taken 
place at one stage or another of the disease. This symptom is 
peculiar, and is characterized as an oozing of serum, in varying 
quantity, which discharges more or less uniformly from the sur- 
face ; it is very properly termed weeping, watering, leeting, dis- 
charging, or running. No other disease has this symptom. It 
may be of the nature of a clear fluid, or puriform ; or it may be 
streaked with blood. The plastic exudation, on the other hand, 
constituting the papule or the patch of eczema, is more difficult 
of recognition, and may be mistaken for other forms of disease, 
to be presently referred to. Following discharge come crusts, and 
those of eczema cannot well be confounded with others. When 
the discharge has been copious, as is commonly the case, the crusts 
form rapidly and in quantity; they are yellowish, greenish, or 
brownish in color, and adhere to a moist surface beneath. The 
amount of cleansing of course modifies the crusting, but it is fre- 
quently so abundant as to mask the skin. 

Of the diagnostic subjective symptoms that of itching is the 
most characteristic. It is usually of an intense character, exceed- 



188 INFLAMMATIONS. 

ing that of other diseases. It is a constant symptom, never being 
altogether absent, although its degree may vary considerably. 
With the itching there is always an irresistible inclination to 
scratch. Burning sensations are often complained of in the acute 
stage, which, as a rule, soon give way to the more decided feeling 
of itching. Finally, it must not be forgotten that two or more 
varieties of the disease may be present at the same time upon one 
patient, otfering a mixture of lesions in various stages of devel- 
opment. 

The diseases with which eczema is liable to be confounded are 
the following : 

Scarlatina. — There may in certain cases be difficulty in dis- 
tinguishing it from this disease; rarely, however, for the general 
symptoms of systemic disturbance in scarlatina are so marked as 
to be significant. There could be doubt only in those cases of 
acute eczema where the eruption is universal. A short period of 
observation would in such instances serve to decide the question. 

Erysipelas. — This is an affection with which it is much more 
likely to be confused, and which may at times resemble eczema 
erythematosum or vesiculosum, particularly when about the face. 
The points of difference, however, are numerous and patent. Ery- 
sipelas is an acute affection, commencing at a point and usually 
extending itself on the periphery as a creeping disease. The in- 
flammation is a deep one, involving the subcutaneous tissues as 
well as the skin, and is attended with great heat, swelling, and 
oedema. The disease is, moreover, accompanied by symptoms of 
fever and general disturbance. The sensations are those of burn- 
ing and of fulness. The skin is deep red, shining, and tense; 
there is no discharge, except from the bursting of bullae, which 
are often present in the latter stage of the affection. This dis- 
charge is very different from that of eczema. 

Erythema Simplex. — Eczema can scarcely be mistaken for 
any of the simple erythemas, or, more properly speaking, hyper- 
emias, for in these disorders there is no inflammation, hypersemia 
being the sole morbid condition. The characteristic features of 
eczema are wanting. 

Urticaria. — The peculiar form of this affection known as 
urticaria papulosa presents lesions looking much like eczema papil- 
losum, especially in children, which fact has given rise to the term 



ECZEMA. 189 

lichen urticatus, a disease which, however, must be viewed rather 
as an urticaria. The diagnosis in these. cases is difficult. As a 
rule, the urticarial element is marked. 

Herpes. — In their early stages herpes zoster and eczema may 
bear resemblance, although the irregular distribution of the vesicles 
of eczema will usually serve to distinguish it from the peculiar 
symptom of grouping in herpes zoster. Eczema is never attended 
with the neuralgic pain which generally accompanies zoster, — a 
feature in itself often sufficient to prevent any confusion in diag- 
nosis. Eczema vesiculosum is more apt to resemble other varieties 
of herpes, especially those forms occurring about the face and 
genitalia. These, however, run their course in a few days as simple 
and mild disorders. 

Pemphigus. — Eczema cannot be confounded with typical pem- 
phigus vulgaris, for here the blebs are isolated and large and have 
a different history from the vesicles of eczema. There is, however, 
a variety of pemphigus, known as pemphigus foliaceus, which has 
certain features resembling eczema. It is, however, extremely 
rare, and, moreover, differs from eczema in its history, course, and 
symptoms. 

Seborrhcea. — Squamous eczema bears many points of close 
resemblance to this affection. The two diseases often present simi- 
lar appearances as they occur upon the scalp. In this region they 
may even at times exist together, the seborrhcea existing either as 
a primary or as a secondary disorder. In eczema the scales are 
larger, less abundant, less greasy, and drier than in seborrhcea. 
In eczema they are, moreover, usually seated upon a circumscribed 
patch, while in seborrhcea, as a rule, they cover the scalp uniformly. 
The skin in eczema is more or less red, inflamed, and thickened, 
and is usually markedly itchy; in seborrhcea it is often even paler 
than normal, and may or may not be itchy. Sometimes, however, 
it is hypersemic, in which case the diagnosis is more difficult. The 
history of the two affections in most cases is sufficiently different 
to render the diagnosis clear and positive. They are both frequent 
affections. 

Psoriasis. — This also is a common disease, and is often con- 
founded with eczema, the appearances frequently being so alike 
that it becomes a matter of difficulty to decide upon the case. Both 
diseases attack all parts of the body ; both are prone to occur on 



190 INFLAMMATIONS. 

the scalp, where the most embarrassment in diagnosis is likely to 
arise. Typical eczema can never be mistaken for psoriasis, but old, 
infiltrated, inflammatory, scaly patches frequently look very much 
like psoriasis. The edges of patches of eczema usually fade away 
into the healthy tissue; in psoriasis, as a rule, they terminate ab- 
ruptly. The scales upon eczematous patches are thin and scanty ; 
in psoriasis they are abundant, and are observed to be larger, 
whitish or silvery, and imbricated. In eczema there will be usually 
some account of moisture at one stage or another of the patch ; in 
psoriasis the process is always dry. The occurrence of the disease 
on other parts of the body will further serve to clear away any 
doubt, while the general history of the disease will also assist 
materially in arriving at a correct diagnosis. 

Lichen Ruber. — Eczema may be confounded with both vari- 
eties of the disease, more especially with lichen planus; the other 
variety, acuminatus, is exceedingly rare in this country. The dis- 
tinctive features of eczema, however, should be remembered; they 
will prove sufficient to establish the diagnosis. The papules of 
lichen planus are flat, and have an irregular or angular base ; those 
of eczema are acuminated or rounded, and have a rounded base. 
Those of eczema, as a rule, are bright red in color; those of lichen 
planus have a dull crimson hue, with a shining aspect, and are 
more or less scaly. The papules of eczema form quickly, and are 
apt to undergo change ; those of lichen planus form slowly, and 
never exhibit any other form, remaining papules throughout their 
course. Lichen planus disappears slowly, and leaves marked 
brownish stains in the place of the papules; papular eczema leaves 
but little pigmentation. In eczema the general health is not seri- 
ously affected; in lichen ruber it may be greatly disturbed. 

Pityriasis Rubra. — This is even a rarer disease than lichen 
ruber, and presents symptoms which might readily be interpreted 
as eczema. It may be distinguished from eczema by its uniform 
redness; great masses of large, thin, papery, whitish, epidermic 
scales, which continually reproduce themselves; slight itching; 
burning heat; and, lastly, by the absence of marked infiltration 
and thickening of the skin, a symptom common in eczema. It 
undergoes but slight changes throughout its course.* 

* For the diagnosis between eczema and the several varieties of dernjatitis, 
some of them rare, the reader is referred to the subject of dermatitis. 



ECZEMA. 191 

Tinea Circinata. — This affection is not infrequently con- 
fused with eczema, especially with the squamous variety. The 
course of the two diseases, however, is unlike, and should alone 
be enough to separate them. Eczema has no tendency to assume 
circular patches, or to produce a marginate or serpiginous course ; 
tinea circinata, on the other hand, has.* In eczema there is no 
history of contagion ; in tinea circinata the disease may often be 
traced to this source. The edges of patches of eczema seldom 
terminate abruptly; those of tinea circinata generally do. Eczema 
tends to run a chronic course; tinea circinata, as a rule, an acute 
one. At times, however, it pursues a slow and insidious course, 
and in these cases is difficult to diagnose from eczema. The itch- 
ing in eczema is usually more marked and severe than in tinea 
circinata, except where the latter disease attacks the genito-crural 
region. Finally, the microscope reveals the existence of a fungus 
in the scales of tinea circinata. f 

Sycosis. — Both varieties of this affection, parasitic and non- 
parasitic, especially the latter, bear considerable likeness to eczema 
of the beard. | 

Tinea Favosa. — The yellowish crusts of eczema often simulate 
those of favus, and mistakes in diagnosis may readily occur unless 
attention be given to diagnostic marks. The crusts of eczema 
pustulosum upon the body can scarcely be mistaken for favus. 
Upon the scalp, however, a common seat of both diseases, there 
is much more liability of falling into error.§ 

Scabies. — This affection in its early stage possesses more fea- 
tures in common with eczema than with any other disease. The 
contagiousness of the disease will be one of the strongest argu- 
ments against the likelihood of the case being eczema. A history 
of direct contagion is usually to be found in scabies. Inflammation, 
papules, vesicles, pustules, and cfusts are all at hand as in eczema, 
and these lesions therefore are of little assistance in arriving at the 

* So-called " eczema marginatum" is regarded by me as ringworm, to which 
subject the reader is referred. • 

f Other points of differential diagnosis between tinea tonsurans and eczema 
of the scalp will be given in describing eczema of the head. 

I The differential diagnosis will be found in the consideration of eczema of 
the beard. 

$ The differential diagnosis of these diseases is given in connection with 
eczema capitis. 



192 INFLAMMATIONS. 

diagnosis. The presence of the sarcoptes, as proved by the burrow 
or by extraction of the mite with a needle, must of course at once 
settle the question. But the demonstration is not always practi- 
cable, for in old cases all signs of the burrows have been destroyed, 
and the intruder is no longer to be caught. The regions of the 
body attacked offer valuable hints for diagnosis. Eczema is rarely 
so diffused as scabies; nor does it show itself in preference so 
markedly about the hands and fingers, axilla?, abdomen, mamma?, 
nipples, penis, and buttocks, all favorite localities for the exhibi- 
tion of scabies. In scabies which has existed for some time, the 
whole body will be seen to be generally involved, the face and 
especially the scalp, however, usually remaining free. Patches of 
disease are not formed in scabies, unless the process has been per- 
mitted to run on for a long time, when they may be produced by 
prolonged scratching. Excoriations and strong applications of 
one kind or another both contribute largely to mask the original 
lesions of scabies, and to render the condition similar to eczema. 
In cases of doubt, the diagnosis may be decided by treatment. If 
the disease be scabies, parasiticides will soon afford relief and sub- 
sidence of the more active symptoms; eczema, on the other hand, 
will, as a rule, not be materially improved by such treatment, and 
may be even aggravated. 

Artificial Inflammations. —Various grades of disease, pro- 
duced by means of cutaneous poisons, acids, alkalies, and similar 
substances, often cause true inflammation of the skin and subcu- 
taneous tissues, which may present an appearance very much like 
acute eczema. The regions affected, the distribution of the erup- 
tion, the uniformity and peculiar character of the lesions, and 
the artificial look which always accompanies these diseases, gen- 
erally afford an insight as to their real nature. If suspected, the 
history, course, and termination will serve to distinguish them 
from true eczema. 

Syphilis. — Eczema of the scalp is more apt to be mistaken for 
syphilis than any other local variety; upon the body it can scarcely 
be confounded with syphilis. A certain form of syphilis occurring 
at times upon the scalp may look very much like ordinary eczema 
pustulosum with fissures ; it will be found, however, upon close 
examination, to be syphilis of a superficial ulcerating form, covered 
by eczematous-looking crusts. It will generally have a disgusting 



ECZEMA. 193 

odor, which symptom alone will sometimes serve to distinguish it 
from eczema. In eczema it is important, in all cases, to remove 
crusts and other secondary matter before pronouncing diagnosis ; 
error may be avoided by attention to this point. The other varie- 
ties of eczema, the papular and vesicular, cannot well be mistaken 
for syphilis. The subjective symptoms, especially itching, are, as 
a rule, absent in syphilis. 

Treatment. — In the consideration of this portion of the subject 
the outlines only for treatment can be given. To enter upon the 
matter fully would carry the chapter beyond the space assigned 
to it. In the first place, it may be stated that eczema is a per- 
fectly curable disease. For its relief two distinct methods of 
therapeusis are employed, one directing its force against the skin 
itself as the offending organ, trusting by this means alone to restore 
health to the part ; the other endeavoring to remedy the disorder 
by the employment of internal or constitutional remedies, intended 
to act against the source of the disease. The plan which appears 
to me to be the correct one, and which in my experience has proved 
most satisfactory, is that which recognizes both local and constitu- 
tional remedies as being of almost equal value. I am confident, 
viewing the matter in a broad light, that this doctrine affords us 
the best results in practice. In some cases, of course, local treat- 
ment is the more valuable, and is to be mainly or entirely relied 
upon. In other cases, the same is true of internal treatment. 

Constitutional Treatment. — Constitutional remedies, if 
judiciously prescribed, prove of decided benefit in the majority 
of cases. They are, however, not demanded in every case, and, 
unless indicated, are not to be recommended. Discrimination in 
this matter is to be exercised. The subject of diet must in the first 
place be referred to. During an attack of the disease it is im- 
portant that the diet be suitable. This remark applies to many 
cases of chronic eczema almost as pertinently as to acute eczema. 
In those cases where the natural habit is full, the food should be 
plain. If there be any disturbance of the digestive tract, all those 
articles of food which are difficult of digestion — as, for example, 
pastry, cakes of all descriptions, gravies and sauces, pork, cabbage, 
pickles, cheese, beer, wine, etc. — are to be interdicted. Exercise 
and fresh air are sometimes beneficial, and not infrequently will 

13 



194 INFLAMMATIONS. 

be found to be valuable adjuvants in the treatment. The state of 
the bowels is always to be noted. They should be open at least 
once a day. Dyspepsia, in any form, should receive prompt at- 
tention, and every meaus be employed to remedy the condition. 
Certain eczemas are both brought on and kept up by this state. 
The condition of the kidneys should be investigated. Diuretics 
are frequently of service. 

Having mentioned in a general way a few of the more promi- 
nent points for treatment, the various remedies which are found to 
be of service may be spoken of. Laxatives are of value in many 
cases, particularly in the highly inflammatory varieties of the dis- 
ease. Saline aperients especially are to be recommended ; among 
these the sulphate of magnesium occupies a conspicuous position. 
It may be combined to advantage with iron, as in the following 
prescription : 

R Magnesii Sulphatis, gi ; 

Ferri Sulphatis, gr. iv ; 

Aqua?, f§iv. 
M. — Sig. Tablespoonful, 
with a gobletful of water, half an hour before breakfast. 

A similar formula containing sulphuric acid, mentioned in con- 
sidering acne, is likewise very valuable. Rochelle salt, cream of 
tartar, and the various other aperient salts are also useful. An- 
other useful tonic aperient, recommended by Anderson, especially 
serviceable where the bowels are easily moved, may be referred to : 

R Sodii Phosphatis, 51 ; 

Acidi Phosphoriei dil., f~v ; 
.Syr. Zingiberis, f^i, Jjiii ; 
Inf. Gentians? Comp., fgvi. 
M".— Sig. Tablespoonful, 
in a large wineglassful of water, thrice daily. 

The laxative mineral spring waters, as, for example, the Ha- 
thorn and Geyser springs of Saratoga, Ofner Rakoczy, Hunyadi 
Janos, and Friedrichshall waters, are also beneficial in many cases. 
In infantile eczema, in those instances where the bowels are irreg- 
ular, good will often be obtained from the employment of syrup 
of rhubarb, alone or with magnesia, in repeated small doses. 

Where there is a coated tongue, with heavy breath, light-colored 



ECZEMA. 195 

evacuations, and constipation, small doses of calomel may some- 
times be administered with good result. At the commencement of 
an acute attack of eczema, cases not infrequently require remedies 
directed against disorders of the stomach, bowels, and secretions. 
Derangements of this character must first be rectified, after which 
other remedies may be prescribed. 

Eczema occurring in old persons, especially in those of a gouty 
or rheumatic disposition, or in those who are bon-vivants, may often 
be successfully treated with diuretics and alkalies, as the acetate 
and carbonate of potassium, in full doses, and liquor potasspe or 
the alkaline natural spring waters. In some cases wine of col- 
chicum may be added with advantage to the mixture. Where a 
stimulant is required, the carbonate of ammonium will be found 
serviceable, as in the following formula given by Anderson : 

R Ammonii Carb., ^iiss ; 

Liq. Potass. Arsenitis, f gi ; 

Syr. Zingiberis, f ^ii ; 

Inf. Cascarillse, f^vi. 
M. — Sig. One tablespoonful, 
with a large wineglassful of water, thrice daily. 

If the patient possess a debilitated constitution, manifesting 
signs of imperfect nutrition or the so-called scrofulous disposition, 
cod-liver oil will prove a valuable remedy. It is of service in 
many cases of eczema, and particularly in children. The prepa- 
rations of iron are also to be recommended ; the syrup of the 
iodide, the tincture of the chloride, and the wine being especially 
useful. Quinine and strychnine, and the various bitter tonics, are 
also valuable adjuvants to treatment, and may be prescribed as 
they may seem indicated. Arsenic is of unquestionable benefit in 
many cases, but, as I have remarked elsewhere (see Part I., Treat- 
ment), it is important to select the case as well as the time for 
its administration. If given to examples of eczema indiscrimi- 
nately, it will prove of more injury than benefit. It is noted not 
infrequently in practice that the disease is aggravated by the 
remedy. In no cutaneous disease is more discretion "called for in 
the employment of arsenic than in eczema. It should never be 
prescribed if there is any disorder of the digestive system. Nor 
should it ever be given in the acute stage of the disease. It is 



196 INFLAMMATIONS. 

likely to do at this time more harm than good. It is found to be 
of especial value in the chronic papular form and in the squamous 
stage of the affection. Tar has in some cases been used internally 
with benefit in the squamous variety of the disease, especially in 
chronic cases. Sulphur spring waters, of which there are great 
numbers in our country, also not infrequently prove serviceable. 

Local Treatment. — For washing purposes, ordinary water 
may be employed ; but in those cases where the skin is delicate, 
distilled water or one of the mucilaginous waters, made from bran 
or flour, should be substituted. Ablutions may be used either hot 
or cold, as may be agreeable to the patient. Too frequent wash- 
ings or general baths are to be avoided ; they have a tendency to 
macerate the already morbid epidermis. For cleansing purposes 
both the soda and potash soaps are made use of. In the majority 
of instances ordinary castile soap suffices; but where the crusts are 
firmly adherent to the skin, or exist in masses, the potash soap 
may be resorted to. 

The treatment of eczema by means of local remedies is of great 
importance, and demands attentive consideration. Many cases may 
be relieved by external means alone. External treatment, of one 
kind or another, is always called for. There are no cases in which 
it may not be used with advantage. It is a matter almost essen- 
tial to successful treatment that the part affected be seen by the 
physician, for it is in the first place to be determined whether the 
disease is acute or chronic, whether the process is in its most active 
stage or is subsiding. The variety of the disease next presents 
itself for consideration ; the primary lesions are to be sought for 
and examined, and the presence of erythema, papules, vesicles, or 
pustules, or the combination of these lesions, established. The 
stage in which the affection exists is to be noted. The amount 
of cutaneous disturbance, heat, redness, swelling, cedema, and 
other abnormal phenomena, are all to be noted, as well as the 
condition of the epidermis, whether intact or lacerated. The 
character of the crusts and scales is of significance, and the pres- 
ence or absence of fissures should be observed. A question of 
moment, moreover, to be ascertained before instituting treatment, 
is the extent of surface involved ; the whole body may be aifected, 
or there may be only a single small or large patch. The region 
attacked must also be taken into account. Finally, the duration 



ECZEMA. 197 

of the disease, its general history as stated by the patient, and, in 
particular, whether a first attack or a relapse, are all matters of 
consequence. 

In almost all cases of eczema there are present certain secondary 
products requiring immediate removal. These consist of crusts, 
scales, and extraneous matter, which have been allowed to collect 
upon the surface. They are to be removed before active remedies 
can be advantageously applied. Crusts, if extensive, are to be 
treated first with oily preparations until saturated and loosened, 
or they may at once be acted upon by water and soap or other 
alkaline washes. The thorough cleansing of the part is a point 
of importance, and, unless insisted upon by the physician, will 
rarely be properly performed by the patient or attendant. Not 
uncommonly, repeated applications of oil, followed by abundance 
of soap and water, are required to secure the desired end. Scales 
are removed without difficulty by the same means. Water and 
soap have thus far been alluded to only as means for cleansing the 
skin. Their uses as curative agents will be presently referred to. 

Acute Eczema. — Caution is to be observed in prescribing for 
the acute eczemas. Remedies which are well tolerated at a later 
stage of the disease will, as a rule, now be found to be too stimu- 
lating. Whatever the remedy applied, it should be at first used 
over a small surface, in order to ascertain whether the effect be 
beneficial or otherwise. Among the many local sedatives which 
from time to time have been recommended for the early stages of 
eczema, with a view of relieving the inflammatory symptoms and 
the itching and burning sensations, I shall mention those only 
which are of most value. It will, however, be borne in mind 
that a preparation which has been of service in one case will not 
necessarily afford relief in another case, bearing even, it may be, 
the same general features; peculiarities of skin have much to 
answer for. If, therefore, one remedy do not succeed, another 
must be tried; and here I would remark that it is often extremely 
difficult to decide whether this or that prescription is best suited 
to the case at hand. The patient soon determines this question, 
however, by the amount of ease obtained. This is the chief end 
to which treatment in this stage of the affection is directed. 

In acute vesicular or erythematous eczema but little soap or 
water should be employed; the parts should seldom be washed, for 



198 INFLAMMATIONS. 

in the majority of instances water irritates the skin. In the place 
of washing, the surface may be powdered from time to time with a 
dusting powder composed of starch and small quantities of oxide 
of zinc and powdered camphor : 



R Pulv. Amyli, gvi 
Pulv. Zinci Oxidi, 



Pulv. Camphors, ^ss. 
M. — Sig. Dusting powder. 

Powders of this description may also be made with lycopodium, 
French chalk, talc, carbonate of zinc, and carbonate of magne- 
sium, in varying proportions, with or without starch. Instead of 
powders, lotions may be employed. I am in the habit of treating 
many cases of acute vesicular eczema with lotio nigra and oxide of 
zinc ointment, according to the following plan, suggested to me 
by Dr. J. C. White. The affected part is to be bathed with the 
lotion, full strength or diluted with equal parts of lime-water, 
applied by means of a sponge or a piece of cloth, for ten or fifteen 
minutes at a time, and at intervals of a few hours or longer; the 
sediment should be permitted to remain on the skin. After the 
application, oxide of zinc ointment is to be rubbed gently over the 
part. As a rule, the itching and burning are relieved at once, and 
the disease is often arrested in its course. A lotion consisting of 
lead-water, eight ounces; glycerine, two drachms, will be found 
useful. Carbolic acid, a drachm, or a drachm and a half; glycerine, 
four drachms; distilled water, a pint, can also be recommended: 
the strength may be increased or diminished according to the effect 
produced. To this four or six fluidrachms of alcohol to the pint 
may often be advantageously added. Dilute hydrocyanic acid, a 
few drachms to the pint, is also a sedative of some value. A 
saturated solution of boracic acid will likewise be found a useful 
remedy. 

The following, prized by Tilbury Fox, may also be used : half 
an ounce of finely levigated (white) calamine powder; two drachms 
of glycerine ; two drachms of oxide of zinc ; and six ounces of 
rose-water. It should be applied frequently, by means of a sponge, 
allowing the sediment to remain upon the skin. A like lotion is 
composed of oxide of zinc, three drachms; glycerine, one drachm; 
lime-water, eight ounces. To this may sometimes be added with 



ECZEMA. 199 

advantage a drachm or two of the "liquor picis alkalinus," or a 
few drachms of alcohol. The following mixture, much used by- 
Mr. Startin, may also be given : 

U Pulv. Calaminse, sji ; 

Cretse Prasparata?, gi ; 

Acidi Hydrocyanici dil., fjss ; 

Glycerinse, fgii ; 

Liq. Calcis, fgiii ; 

Aq. Sambuci, f^ivss. 
M. et ft. lotio. 

The fluid extract of grindelia robusta is another good remedy, 
used as a lotion, in the strength of a drachm or two to from four 
to eight ounces of water. It should be used, however, cautiously. 
A lotion composed of two drachms of the " liquor carbonis deter- 
gens," * one drachm of glycerine, and four ounces of rose-water, 
will be found suitable to many cases. I have moreover used with 
benefit in diffused vesico-papular eczema a lotion of thymol, ten 
or fifteen grains ; glycerine, two drachms ; alcohol, one ounce ; 
water, seven ounces. 

Weak alkaline lotions, as, for example, one drachm of bicar- 
bonate of sodium or half a drachm of borax to eight ounces of 
water, may also be tried. Cloths steeped in hot water, as hot as 
can be borne, and wrung out and applied to the parts, at times 
afford temporary relief from the itching. 

In many cases, however, ointments answer better than lotions. 
The oxide of zinc ointment is a well-known and excellent prep- 
aration, admirably adapted for many cases, and may be employed 
either alone or with other remedies. If it be benzoated, only a 
very small quantity of benzoin should be used. • To make it more 
sedative, a drachm of spirit of camphor may be added to the 
ounce, as suggested by Wilson. Oleate of zinc, in the form of an 
ointment, as recommended by Crocker, is also a useful prepara- 
tion, f It may be prescribed with three or four parts of petroleum 



* An alcoholic solution of coal tar. It is prepared by "Wright & Co., of 
London ; also by L. Wolff, of Philadelphia. 

f Dr. Crocker gives the following directions for making the oleate of zinc. 
Take one part of oxide of zinc and eight parts of oleic acid ; stir together ; 
allow to stand two hours ; heat until dissolved. On cooling, a yellowish- 



200 INFLAMMATIONS. 

ointment, olive oil, or lard. The following formula is one which 
I frequently use : 

R Zinci Oleatis, ^iss ; 

Adipis Benzoati, giii ; 

Vaselin., 31 v ; 

Bals. Peruv., gr. v. 
M. Ft. ungt. 

The oleate and subnitrate of bismuth are also serviceable in the 
form of an ointment, of similar strength. Camphor may also be 
employed in the form of an ointment, alone or with oxide of zinc 
and glycerine. The appended formula makes an acceptable oint- 
ment which may be used iu the early stage of vesiculation : 

R Pulv. Camphors?, J}i ; 

Pulv. Zinci Oxidi, s;ii ; 

Glycerins?, f^ss ; 

Adipis Benzoati, gvi. 
M. Ft. ungt. 

McCall Anderson has given the following formula for a sooth- 
ing ointment, useful in many conditions : 

R Bismuthi Oxidi, gr. xv; 

Acidi Oleici, _^ii ; 

Cera? Albs?, ^iss ; 

Vaselin., jjivBS ; 

01. Rosse, ny. 
M. Ft. ungt. 

Oxide of zinc may be substituted for the oxide of bismuth. 



white hard mass results, which may be variously made into an ointment. 
(Brit. Med. Jour., Oct. 26, 1878.) Mr. L. Wolff, of Philadelphia, who has sup- 
plied me with a superior oleate of,zinc, writes as follows concerning its manu- 
facture. " A true zinc oleate is best made by double decomposition of sodium 
oleate with zinc sulphate. The sodium oleate can be made by saturation of 
oleic acid with a solution of potassium hydrate and precipitation therefrom 
of the sodium oleate by sodium chloride. It is then expressed and dissolved 
in about eight times its weight of boiling water, and then the zinc oleate 
precipitated with a saturated solution of zinc sulphate. This precipitate is 
well washed with hot water, expressed, and reduced to an impalpable powder. 
For ordinary purposes zinc oleo-palmitate will answer. It is made by saponi- 
fying oil of sweet almond, dissolving the sodium oleo-palmitate so formed, 
and precipitating it in the aforesaid manner. Zinc oleate should be a white 
powder, of an unctuous touch, and perfectly soluble in warm oils or fats." 



ECZEMA. 201 

Diachylon ointment, made according to the formula of Hebra, 
is a very useful preparation. It is most effective when spread 
upon cloths and applied closely to the skin by means of bandages. 
It is prepared as follows : 

R Olei Olivse Opt., fgxv; 

Lithargyri, giii, gvi ; 

Aquse, q. s. 
Coque. M. Ft. ungt* 

An elegant ointment may also be made according to the follow- 
ing formula of Mr. Moritz Eisner : Dry pure oxide of lead, one 
part ; distilled water, one part ; olive oil, eight parts ; oil of rose, 
one drop to the ounce. Rub the oxide with water, add the oil, 
and heat on a water-bath to almost the boiling point until the 
oxide of lead has thoroughly combined with the oil, then cool with 
constant stirring. 

A similar ointment may be prepared with one part of oil of 
sweet almond to two parts of lead plaster, as suggested by R. W. 
Taylor. Equal parts of lead plaster and petroleum ointment, as 
proposed by Piffard, also constitute an elegant ointment, which will 
be found useful.f Olive oil, equal parts of olive oil and lime- 
water, oil of sweet almond, and dilute glycerine may also be used 
as soothing dressings; likewise cold cream, cucumber ointment, and 
glycerole of starch. 

In eczema papulosum the inflammation is not diffuse, as in 
the vesicular and erythematous varieties, but is circumscribed, the 

* The following directions are necessary. The oil is to he mixed with a pint 
of water, and heated hy means of a steam-bath to boiling, the finely-powdered 
litharge being sifted in and stirred continually ; the boiling is to be kept up 
until the minute particles of litharge have entirely disappeared. During the 
cooking process a few ounces more of water are to be added from time to time, 
so that when completed water still remains in the vessel. The mixture is to 
be stirred until cool. It should be of a yellowish color and of the consistence 
of butter. The best olive oil and the finest litharge should be employed. In 
addition to the method given for its preparation, it may also be made with 
four parts of diachylon plaster and two or three parts of olive oil, the two 
substances being melted, and stirred until cool. The proportion of the oil 
necessary to produce a firm ointment will vary with the consistence of the 
plaster. Messrs. McKelway, Kemington, Eisner, and Wolff, apothecaries, 
have furnished me, from time to time, with a satisfactory preparation. 

f In both of these ointments the proportions must vary with the seasons. 



202 INFLAMMATIONS. 

papules being usually discrete. The inflammation, consequently, 
is of quite a different character, and pursues, as a rule, a more 
chronic course. Soothing applications are of little benefit here; 
more stimulating remedies, as the various so-called antipruritics 
used in the chronic stage of the disease, will be found of more 
service than bland preparations. Carbolic acid, as a lotion, is the 
most valuable remedy which we possess for papular eczema. The 
formula already given will be found suitable for many cases. 
Thymol, a few grains to the ounce of alcohol and water, is also 
useful. The following may likewise be given: "liquor carbonis 
detergens," three or four fluidrachms; glycerine, two fluidrachms; 
rose-water, five fluidounces. The "liquor picis alkalinus" di- 
luted with water and glycerine, half a drachm or a drachm to 
the ounce, is also frequently serviceable. Lotions are much to be 
preferred over ointments for the treatment of this variety of the 
disease. 

It need scarcely be remarked that it is impossible to draw the 
line definitely between acute and chronic eczema, — to state exactly 
when the former passes into the latter. In practice, however, it 
is found that, as a rule, the acute stage is brief, lasting usually from 
a few days to a fortnight. In the selection of remedies the phy- 
sician must be guided rather by the pathological changes which 
have taken place than by the length of time the disease has 
existed. Some of the remedies to be referred to presently in 
speaking of the local treatment of chronic eczema may at times 
be used with benefit early in the course of the disease. I shall, 
however, refer to this subject again in considering the treatment 
of the disease as it attacks particular regions of the body. 

Chronic Eczema. — After a few days or weeks, the acute 
process will, in most instances, have subsided to a great extent, 
and other remedies will be found more serviceable. Crusts should 
never be permitted to form ; they should be removed by the means 
already indicated. In some cases the treatment just referred to 
for the acute stage serves also for later stages ; more stimulating 
applications, however, are usually required. 

Carbolic acid, in varying strength, here, as in the acute stage, 
is one of our most useful remedies ; it may be employed in the 
form either of lotion or of ointment. In the proportion of ten or 
fifteen minims to the ounce of ointment it will be found serviceable 



ECZEMA. 203 

in both vesicular and erythematous eczema ; it may be combined 
advantageously with the benzoated oxide of zinc ointment, and 
also with the oleate of zinc ointment. It is a valuable antipruritic 
remedy, and is one of the few substances which may be relied upon. 
In this connection thymol, recommended by Crocker,* in the form 
of an ointment or lotion, in the strength of from five to ten grains 
to the ounce, may also be mentioned. Somewhat similar in effect 
to carbolic acid are the preparations of tar, which are the most 
serviceable of all external remedies. To obtain good results they 
must be handled with care : unless used at the proper time and in 
suitable strength, they serve only to irritate, and when this occurs 
they are to be abandoned at once. Tar is of most benefit when 
the disease has reached the chronic stage. It is never to be ap- 
plied in the very acute stage. If there be much inflammation, 
swelling, and oedema, it likewise should be withheld. The more 
chronic the condition, the more likelihood is there of its being 
tolerated. The mode of application, and the strength, are to be 
determined as the disease is upon one part of the body or another. 
Ointments of varying proportions are the most suitable means 
of applying it ; for, in addition to its stimulating properties, an 
emollient effect is to be obtained. The ointment should not be 
too strong; from one to two drachms of the tar to the ounce are 
usually sufficient. The two forms of tar commonly used are pix 
liquida and oleum cadinum. They may be applied in the same 
manner, and have a similar effect upon the skin. 

R Olei Cadini, fcpss ; 

Cerati Simplicis, ^i ; 

01. Amygdal. Amar., gtt. x. 
M. Ft. ungt. 

This constitutes one of the most elegant of the tarry ointments. 
Half a drachm of the "liquor picis alkalinus," or a drachm of the 
" liquor carbonis detergens," to the ounce of ointment, will also 
be found serviceable. Fluid preparations are better adapted to 
the scalp than ointments. Thus, tar is sometimes employed with 
excellent result upon the scalp combined with alcohol, as in the 
appended prescription : 

* Brit. Med. Jour., Feb. 16, 1878. 



204 INFLAMMATIONS. 

R Picis Liquids, f^i ; 

Glycerinse, fji ; 

Aleoholis, fgvi ; 

01 Amygdal. Amur., gtt. xv. 
M. — Sig. To be rubbed firmly into tbe skin. 

In whatever way it is employed, the part should be well rubbed 
with it twice daily by means of a piece of flannel rag. The oint- 
ment should not merely be smeared over the surface, but firmly 
rubbed in for ten or fifteen minutes. A small quantity should be 
used for each application, which should be worked into the skin 
until it has been quite consumed. The same directions apply to 
the fluid preparations. Tar is also advantageously combined with 
soap in the treatment of eczema. In the thick, leathery patches 
of chronic disease, equal parts of alcohol, sapo viridis, and pix 
liquida may be applied in the same way as the other preparations 
mentioned. To produce a stronger impression, potassa may be 
used in place of the soap, in the strength of from five to fifteen 
grains to each ounce of the mixture. Dr. Bulkley has given to 
the profession a valuable alkaline tarry preparation, which pos- 
sesses the advantage over the plain tar in that it combines with 
water. The following is the formula : 

B Picis Liquid;*?, fcjii ; 
Potasss Caustics, 31 ; 
Aquae Destillatae, f^v. 
M.* — Sig. " Liquor Picis Alkalinus." To be used diluted. 

It may be used in the form of a lotion or with ointment. As a 
lotion, it is to be diluted with water, — from one to four or more 
drachms to the pint, according to the state of the skin and the 
effect desired. Care should be observed not to make the mixture 
too strong at first. In infiltrated, localized patches it can, of 
course, be employed much stronger, as, for example, one part to 
five or ten parts of water, followed by the use of some ointment. 
It may also be combined with ointment, from one to two drachms 
to the ounce. It is similar in its composition, though stronger, 
to the French preparation known as " goudron de Guyot," which 
may also be recommended. 

* The potassa is to be dissolved in the water, and gradually added to the 
tar with rubbing in a mortar. 



ECZEMA. 205 

Various soaps are employed in the treatment of eczema. Com- 
mon hard or soda soap, of which the variety known as castile is 
the type, may be used for purposes of ordinary cleansing, but to 
obtain stronger detergent effects the potash soaps are brought into 
requisition, and they perform an important part in the handling 
of certain eczemas. It must be remembered that all soaps are 
more or less alkaline, as they are hard or soft, and according to 
their quality, and that unless ordered judiciously they may be 
productive of mischief. This remark applies particularly to the 
strong potash soaps known under the names of sapo mollis, sapo 
viridis, black soap, brown soap, and soft soap, which contain a 
certain amount of free alkali. Sapo viridis has numerous uses 
in eczema. It may be employed alone, or with alcohol in the form 
of an alcoholic solution. (See p. 125.) , It is an indispensable 
detersive agent, and may frequently be applied to cleanse patches 
of their crusts and scales previous to the use of other remedies.* 

It is in the condition which has been described under the name 
of eczema rubrum that sapo viridis is found of greatest value.f It 
is in these cases employed systematically and in conjunction with 
an ointment. The more localized the disease, the better are the 
chances for success ; in fact, it may be stated that, as a rule, this 
plan of treatment is to be adopted only in cases where the disease 
is confined to one or several patches. Where the eczema is dif- 
fused, and is upon various parts of the body, other methods answer 
better. In the frequent, chronic eczemas of the legs, it is the 
treatment par excellence. It may generally be relied upon in these 
cases when other remedies have failed. It is also to be directed 
in certain other local forms, as, for example, in infiltrated eczemas 
of the hands and arms, in chronic eczemas of the face, and, indeed, 
in all cases where the affection is localized upon a particular region. 

The treatment consists in the application of the soap, followed 

* In order to secure uniform results from the use of the soap, it is well to 
make use always of an article which is known to possess a definite strength. 
That obtained from Duvernois, Stuttgart, and from Bassermann and Her- 
schel, Mannheim, Germany, is the most reliable with which I am acquainted. 
It is manufactured on a large scale at Worms. It is imported by Messrs. 
McKelway, Kemington, and Wolff, of this city. 

f To Hebra belongs the honor of having been the first to institute the 
method of treatment about to be described. To have it prove successful it is 
essential that the instructions for its performance be faithfully carried out. 



206 INFLAMMATIONS. 

immediately by the use of an oily ointment. Soap applied alone, 
in any form of eczema, acts as a mild caustic and as an irritant, 
and, as a rule, tends only to increase the disease. This is a point 
never to be lost sight of; much damage is often inflicted by the 
indiscriminate and too free use of strong soap. The ointment used 
in preference by Professor Hebra, and the one which is unquestion- 
ably the best, is the diachylon ointment already spoken of. The 
accompanying instructions are to be adhered to. A lump of the 
soap, the size of a small nut, is smeared upon a piece of wet 
flannel ; this is to be applied directly to the patch of disease, and 
rubbed firmly and with moderate pressure upon the skin until 
all traces of the soap have disappeared. The piece of flannel may 
now be dipped into warm water and again applied in the same 
manner to the part, when an abundant lather will be formed. More 
water from time to time may be added, until copious suds cover 
the skin, when the diseased surface is thoroughly washed off, freed 
from all signs of soap, and carefully dried. The rubbing should 
be performed with a certain amount of force, to be regulated by 
the amount of infiltration, the region affected, and the sensibility 
of the skin. The time occupied in the process also must be gov- 
erned by the effect produced; in slight cases five or ten minutes 
may prove sufficient, while in thick infiltrations, especially upon 
insensible regions of the body, twenty or thirty minutes may be 
advantageously expended at each operation. The first application 
should always be somewhat moderate, that too great a destruction 
of epidermis be not produced, thereby causing soreness. The sen- 
sations of the patient will, however, always serve as a guide upon 
this point. The application is not painful, as might be supposed, 
but, on the contrary, is usually agreeable, destroying the itching. 
The part immediately after the washing presents a red appearance, 
the skin being clean, tense, and shining. Here and there minute 
puncta may often be seen, from which clear serum oozes out in 
pin-point drops. 

The part is now ready for the ointment, which should be pre- 
pared before the washing is begun, so that no time may be lost in 
applying it. The ointment is to be spread upon strips or pieces 
of soft, flexible muslin which have been cut to the size of the 
patch or extent of diseased surface. It is not well to make one 
large piece cover the whole, but is preferable to have several 



ECZEMA. 207 

pieces, in order that they may be better adapted to the surface. 
The ointment should be spread upon the rags as thick as the back 
of an ordinary table-knife. The part is now to be enveloped with 
these cloths in a neat manner, so that no folds or wrinkles may 
occur. Finally, it should have outside cloths applied, to prevent 
the oil from oozing through, and be bound down by means of a 
bandage. This is also a matter of moment, for its proper appli- 
cation contributes materially to the success of the treatment. It 
is essential that the ointment be brought into close contact with 
the skin, and that it be kept in this position. The patient may 
be permitted to go about as usual. The entire operation is to be 
repeated in the same manner twice daily. Usually improvement 
will be noticed at once. The patient will obtain relief from the 
itching at the first rubbing with the soap, and decided comfort 
after the ointment has been on for a short time. 

In extensive and old patches of eczema it is at times necessary 
to have recourse to a more powerful caustic than the sapo viri- 
dis, in which case a solution in water of potassa may be applied. 
The strength may vary from ten grains to half a drachm or 
even a drachm to the ounce ; but extreme caution is necessary in 
the use of such strong remedies, which should in every case be 
employed by the physician himself. The stronger the application, 
the less often should it be repeated; once every other day, or twice, 
or even once a week, will in most cases be sufficient. The effect 
of the caustic in these cases should be moderated by cold-water 
cloths and compresses, after which the unguentum diachyli may 
be used as described. 

There are numerous other remedies and modes of treatment for 
the chronic stage of eczema, some of which are of great value and 
may here be referred to. The mercurial preparations occupy the 
first place in the list, and will be found exceedingly useful in many 
cases, particularly where the disease is confined to a small area 
without tendency to spread. Calomel is without question the most 
valuable, in the strength of half a drachm or a drachm to the 
ounce. The red oxide of mercury, varying in strength from five 
to twenty grains to the ounce, and ammoniated mercury, from 
twenty to forty grains to the ounce, are also of value. The latter 
is less severe in its action than the red oxide, and may often be 
prescribed with good result in the pustular eczemas of children. 



208 INFLAMMATIONS. 

The other mercurials, as the corrosive chloride, red iodide, black 
oxide, nitrate, and bisulphuret, may also be used. It must be 
remembered that there is a slight risk of salivation, even when 
applied to small surfaces, and that occasionally persons are met 
with who are extremely susceptible. Sulphur in the form of an 
ointment, from one to three drachms to the ounce of vaseline, at 
times acts very beneficially. Boracic and salicylic acids are also 
useful. Boracic acid ointment, sixty or eighty grains to the ounce, 
will be found especially useful in mild cases of erythematous 
eczema. Where ointments are not tolerated, a saturated solution 
of boracic acid may often be used in the same cases with benefit. 

The glycerole of the subacetate of lead, brought forward prom- 
inently by Balmanno Squire,* may here be referred to. It is a 
useful preparation, and may be especially recommended, of the 
strength of from fifteen to thirty grains to the ounce, in eczema 
rubrum of the lower extremities. It is most valuable where the 
disease is extensive, of a dusky-red hue, accompanied with weep- 
ing, infiltration, cedema, and swelling, and in varicose conditions.f 

For obstinate circumscribed patches blistering with cantharides 
will sometimes be found serviceable. A similar result may be 
obtained from carbolic acid diluted with alcohol, from tincture of 
iodine, and from nitrate of silver. Vulcanized india-rubber is 
also a useful therapeutic agent. In the form of the solid rubber 
bandage or sheet, applied closely to the part, it serves to protect 
the skin and to exclude the air, and has a decided curative effect. 
When practicable, it should be employed continuously, day and 
night, It should be removed and cleansed once or twice in the 
twenty-four hours, when the skin may be wiped or rubbed dry 
with a rag, and the bandage or cloth reapplied.! 

* Med. Times and Gaz., March 18 and 25, 1876. 

f See a contribution to the subject, with cases, by Dr. Van Harlingen and 
myself, Phila. Med. Times, Aug. 3, 1878. The formula of Mr. Squire is as 
follows : Acetate of lead, 5 parts ; litharge, 3J parts ; glycerine, 20 parts, by 
weight. Mix, and expose to a temperature of 350° F., and filter through a 
hot-water funnel. The clear viscid fluid resultant contains 120 grains of the 
subacetate of lead to the ounce. This is used as a stock from which the 
preparations employed are made by dilution with glycerine. 

X For further information on the treatment of eczema, the reader is referred 
to the monographs of Anderson (A Practical Treatise upon Eczema, in- 
cluding its Lichenous and Impetiginous Forms. Third edition, with illus- 



ECZEMA. 209 

Prognosis. — This must depend materially upon the circum- 
stances attending the case in question. It may, however, be stated 
that the disease is always curable. There are a number of points 
which should be taken into consideration before an opinion is 
given as to the probable duration. The general health and con- 
dition are, in the first place, to be investigated ; and in this con- 
nection the cause of the disease is, if possible, to be ascertained. In 
general diffused chronic eczema this question is one of the greatest 
importance, upon which the prognosis must entirely depend. The 
variety of the disease is next to be determined; whether the ele- 
mentary lesions appear in a regular manner, or whether they incline 
to irregularity and polymorphism. 

It is well known that certain varieties of eczema usually run 
obstinate and long courses, while others tend to recovery after 
reaching a certain stage. Acute inflammatory eczema vesiculosum, 
for example, is apt to run a short and definite course, while, on the 
other hand, eczema papulosum is prone to be chronic. The stage 
of the eruption is also to be taken into account, as well as the dura- 
tion of the disease; further, whether it is a first attack or a relapse. 
It is, moreover, of moment to ascertain whether the disease be 
acute or chronic ; whether the process tend to terminate sponta- 
neously, or to run on indefinitely, with secondary changes. 

The location of the eruption is also to be considered, for eczema 
of certain parts of the body is almost invariably obstinate. Upon 
the head and ears it is usually troublesome, and often tends to be 
chronic. About the nose and mouth the erythematous variety is 
generally unyielding. Eczema of the scrotum is likewise at times 
very rebellious. About the legs in old people, more particularly 
if complicated with varicose veins or ulcers, it is also more or less 
intractable. 

Local Vaeieties of Eczema, their Diagnosis and Treat- 
ment. 
Eczema may show itself upon any part of the body. No region 
is exempt. It may manifest itself upon a small portion of the 



trations. Phila., 1875) and Bulkley (The Management of Eczema. New 
York, 1882). The last-named work is the most comprehensive treatise on the 
subject, and is a valuable contribution to literature. 

14 



210 INFLAMMATIONS. 

body only, or it may involve the whole integument. When the 
entire surface is affected, leaving no portion of the skin free, it is 
termed eczema universale, the variety of the disease being in 
this event either erythematous or vesicular : so extensive a distri- 
bution of the disease, however, is of rare occurrence. Usually it 
appears in the form of one or more irregularly-shaped patches, 
varying in size from a small coin to the palm of the hand. It 
attacks certain regions of the body in preference. Inasmuch as 
it exhibits peculiarities of appearance and course as it is located 
upon one part or another, it will be necessary to give a description 
of the commoner of these so-called local varieties. I shall at the 
same time speak of their differential diagnosis and special treat- 
ment. 

Eczema Capitis. — Eczema is frequently encountered upon the 
head, usually in the erythematous, the vesicular, or the pustular 
form. The former variety, as a rule, at once tends to take on a 
chronic course, and soon settles into the stage which is known as 
eczema squamosum. The patches are usually irregular in outline, 
and may occur either singly, as is generally the case, or in numbers 
upon any region. The disease may also involve the whole scalp. 
The itching is generally marked. 

The pustular variety is commoner in children and young persons 
than in adults. It exists either in the form of a few patches of 
pustules, occurring here and there, or, as is much more likely to be 
the case, takes possession of the whole scalp. The pustules usually 
appear in great numbers, for the most part about the hair-follicles; 
they soon rupture, and the liquid oozing over the surrounding skin 
dries into greenish-yellow crusts. As the process goes on and new 
pustules are produced, which undergo the same course, the crusts 
become thicker and more bulky, until in time the whole scalp may 
be covered with a cap of crust. The hair becomes matted and 
caked, the sebaceous secretion collects, and soon, if the part be not 
frequently cleansed, the head becomes offensive. In this descrip- 
tion we have a typical eczema pustulosum, which applies to adults 
as well as to children. The disease may last a few weeks, or for 
months or years. The itching is usually not so decided as in the 
other varieties. 

Accompanying severe cases of pustular eczema of the head it 
is not uncommon to observe marked enlargement of the subcuta- 



ECZEMA. 211 

neous glands of the neck ; they become swollen, and may present 
a bunchy appearance. The condition occurs particularly about 
the back of the neck, and also back of the ears. They are sym- 
pathetically affected, and increase and diminish in size as the dis- 
ease is worse or better. They never suppurate, but may continue 
until the eczema disappears. Small abscesses are often met with 
upon the heads of unhealthy children, which tend to complicate 
the original affection. Pediculi are not infrequently found in con- 
nection with eczema capitis in children, either as a primary cause 
or in consequence of the matted condition of the hair constituting 
a favorable habitat for them. They are a common source of the 
affection among the poorly nourished and ill cared-for, and their 
presence or absence should be established at once. When present, 
they are exceedingly mischievous, and call for active treatment. 
They are apt to escape notice, owing either to the fact of their 
not being numerous, or to long and thick hair, which may conceal 
them. The nits, however, are usually to be found adhering to the 
hairs, and quite remote from the scalp. 

The diagnosis of eczema capitis is at times difficult; it may be 
confounded with psoriasis, seborrhoea, favus, syphilis, tinea favosa, 
and tinea tonsurans. It may often be distinguished from psoriasis 
by its tendency, during some period of its course, to show moist- 
ure ; psoriasis is never moist. In eczema the edges of the patches 
are not abrupt, but fade away into the healthy skin ; in psoriasis 
the patches usually have defined borders. Eczema generally shows 
crusts if there has been any fluid exudation, or small fine scales 
if in the squamous stage ; psoriasis presents the typical dry, thick, 
imbricated, whitish scales. Eczema may or may not involve the 
head alone ; psoriasis of the head usually shows signs of its pres- 
ence upon other regions of the body. Eczema of the head com- 
monly occurs in the debilitated ; psoriasis oftener in the robust. 
Eczema of the head is generally more itchy than psoriasis. In 
doubtful cases, the history and course of the affection may be of 
service in arriving at a diagnosis. 

Eczema and seborrhcea not infrequently bear a close resemblance 
to each other. Eczema is prone to occur in patches, which, how- 
ever, are seldom numerous; seborrhoea generally invades the whole 
scalp uniformly, or in numerous variously sized, ill-defined patches. 
The fluid discharge and consequent crusts of eczema are to be re- 



212 INFLAMMATIONS. 

membered ; in seborrhoea there is no discharge, the product being 
composed of fine or coarse scales, of an oily or dry nature, which 
cake together and adhere to the scalp. Eczema is a much more 
acute and rapid process than seborrhoea, often making its appear- 
ance suddenly ; seborrhoea, as a rule, develops itself by degrees. 
Eczema is markedly itchy ; seborrhoea seldom so to the same 
extent, and often not at all so. Patches of squamous eczema are 
red and infiltrated ; those of seborrhoea are generally pale red or 
bluish, and are not infiltrated. 

Eczema can only be confounded with tinea favosa when it is of 
the pustular variety; in such cases the two diseases may readily be 
mistaken for each other, as the crusts have features in common. 
In eczema, however, the crusts are the result of previous pustules; 
in tinea favosa the crusts are peculiar, having begun primarily as 
crusts. The crusts of eczema are greenish yellow : those of tinea 
favosa are lemon or sulphur yellow; moreover, they are, when per- 
fect, cup-shaped, rounded, discrete or confluent, tending to preserve 
their original shape; they form slowly, and are dry and friable. 
Sometimes the irritation of the skin produced by the parasite is so 
great as to cause a suppurative dermatitis about the crusts, in which 
event the diagnosis may be even more difficult. The odor about an 
eczematous head is often nauseous; about tinea favosa, where the 
disease is extensive, it is characteristic, being mousy. The micro- 
scope establishes the diagnosis at once, the crusts of tinea favosa 
being composed almost entirely of fungus, whose elements may be 
readily discovered under a power of three hundred diameters. 

Eczema erythematosum or squamosum may readily be con- 
founded with tinea tonsurans. Not infrequently the diagnosis is 
extremely difficult, especially in chronic cases, until the microscope 
is employed. The following clinical features may be mentioned. 
The patches of eczema are not attended with loss of hair; in tinea 
tonsurans many of the hairs are broken off more or less uni- 
formly about an eighth or a quarter of an inch beyond the scalp, 
looking as though the patch had been c'osely cut. The hair in 
marked cases has a nibbled look. The follicles, moreover, are 
always diseased, causing the skin to have a goose-flesh appear- 
ance. The patches of recent tinea tonsurans are often circular or 
in segments of circles; in eczema they are usually roundish, but 
seldom sharply defined. The hairs in tinea tonsurans have a lus- 



ECZEMA. 213 

treless, dried, twisted, brittle appearance, and come out readily ; 
in eczema they remain firm, unless scratched out by the patient. 
In dark-haired subjects the scalp has a dull, leaden color in tinea 
tonsurans. Even in light-haired subjects the inflammatory symp- 
toms are rarely so marked as in eczema. Where tinea kerion 
exists, however, and where the disease is chronic, the diagnosis is 
more difficult. In doubtful cases the microscope should always 
be employed. The itching in eczema is marked ; in tinea ton- 
surans it is often comparatively slight. A history of contagion is 
frequently to be found in connection with tinea tonsurans. 

Certain late forms of syphilis of the scalp may be mistaken for 
eczema, and in these cases the diagnosis may be obscure. The 
crusts may be similar, but there are generally signs of ulceration in 
syphilis, which are altogether wanting in eczema. The ulcers are 
observed to have abrupt edges, and to have unhealthy-looking, 
grayish .bases, with an abundant, thick, creamy or streaked secre- 
tion. There is no itching of any moment in syphilis, but in eczema 
it is usually marked, and is often excessive. The odor attached to 
syphilis of the scalp is usually penetrating and disgusting. The 
history of the case may be of value in assisting the diagnosis. 

The treatment of eczema capitis will depend upon the variety 
of the disease, upon the stage it is in, and upon the state of health 
of the patient. The age of the patient must also be taken into 
consideration. If the case be of the pustular variety, it is of the 
first importance to have the crusts thoroughly removed; this is best 
accomplished by saturating the scalp with olive or sweet almond 
oil, and then washing with warm water and soap. If the crusts 
be in quantity and adherent, it will be necessary to allow the oil 
to remain on the head all night, a flannel skull-cap and bandage 
being put over the head. In severe acute cases, where the pustules 
are appearing from day to day, the application of oil, in the manner 
just described, constitutes in itself an excellent dressing, and may 
be employed at times when other remedies prove too stimulating. 
Glycerine and water, oue part to two or three, or one of the petro- 
leum ointments, will also be found useful ; likewise lime-water 
and olive oil with the addition of five or ten grains of carbolic acid 
to the ounce. It is rarely if ever necessary to shave or to cut the 
hair. The value of a head of hair for a woman more than coun- 
terbalances the slight benefit derivable from its removal. In young 



214 INFLAMMATIONS. 

children and in boys, however, the hair in severe cases, especially 
if complicated with pediculi, may be cut close, in order that the 
part may be better attended to and the applications more thor- 
oughly made. If nits be present in numbers, they, too, may be got 
rid of more promptly in this way. In inflammatory cases, lotio 
nigra or one of the carbolic acid lotions may be dabbed on the scalp 
for ten or fifteen minutes at a time, morning and evening, followed 
by an oily preparation. An ointment composed of from half a 
drachm to one drachm of the mild chloride of mercury to the ounce 
will be found of value, directions being given to use a small quan- 
tity, and to have it well rubbed in. In cases where washing and 
frequent cleansing appear to increase the inflammation, this pro- 
ceeding had better be omitted for a few days. The ammoniated 
mercury in the form of an ointment, fifteen to forty grains to the 
ounce, also answers well ; should there be pediculi present, it will 
also serve as a parasiticide. Ten grains of the red oxide of mer- 
cury to the ounce of vaseline may likewise be used. 

Patches of squamous eczema require a stimulating treatment 
similar to that employed upon other portions of the body. The 
most valuable remedies are the tarry preparations, in the form of 
ointment or lotion, which, in one strength or another, will be tol- 
erated in the majority of cases ; instances, however, occur where 
they cannot be employed, owing to some peculiarity of the skin. 
One drachm of tar or of oil of cade to the ounce of alcohol, and 
the tincture composed of equal parts of sapo mollis, tar, and alco- 
hol, form admirable mixtures for the more chronic cases, where 
decided stimulation is required. A milder preparation, composed 
of half a drachm or one drachm of oil of cade to the ounce of oil 
of sweet almond, is also useful. The various other stimulating 
preparations may be employed as occasion may demand. 

Eczema Faciei. — The face is a common seat of eczema. The 
disease here may be either acute or chronic. The erythematous 
variety is frequently encountered here in adults, in the form of 
patches about the forehead, cheeks, and other regions. The ve- 
sicular and pustular varieties are also frequent here, especially in 
children. "Where the disease of the scalp is extensive, it is apt 
to spread itself somewhat over the forehead. The surface may 
be simply red, infiltrated, and slightly squamous, or it may show 
signs of moisture with crusts. Eczema of the face occurs much 



ECZEMA. 215 

more frequently in infants and children than in adults. The nose, 
especially about the alas and nares, is not an infrequent situation 
for erythematous eczema in adults, where it is usually stubborn. 
The upper lip may also be involved. The itching is generally 
severe. Carbolic acid ointment I find especially useful in these 
cases. The oleate of zinc, a drachm to the ounce, with twenty or 
thirty grains of calomel, may also be recommended. 

Eczema Labiorum. — The disease occasionally attacks the lips, 
either alone or in connection with other parts of the face. One or 
both lips may be affected. The symptoms are swelling, redness, 
heat, infiltration, slight scaliness, and fissures. The skin around 
the border of the mouth may be the seat of the disease, or the 
vermilion of the lips and mucous membrane may be attacked. 
The mouth may be contracted, and the lips partly glued together 
by the exudation and crusts. The mucous membrane may be 
involved to such an extent as to be partly devoid of epithelium. 

Both herpes labialis and syphilis possess features which may be 
confounded with eczema. Herpes always runs an acute course, 
lasting at most only a short period, and, moreover, shows itself 
in the form of a group or groups of vesicles. Eczema invades 
a greater amount of surface, and is invariably obstinate in its 
nature. Syphilis occurring about the mouth has a predilection 
for the angles, where it is usually localized ; the fissures are often 
deep, and generally secrete a puriform product. 

The treatment of this variety of eczema is difficult, and is 
attended with discomfort for the patient. Either strong or, on 
the other hand, mild applications are found to be of most service. 
Potassa or nitrate of silver solutions, carbolic acid and alcohol or 
carbolic acid and glycerine, half a drachm to the ounce, tar oint- 
ment, and other heroic remedies, may be tried ; or, on the other 
hand, it may be that more relief is afforded by the emollient 
ointments and lotions, such as glycerine and water, oil of sweet 
almond, vaseline, and like preparations. 

Eczema Palpebrarum. — This occurs often in children of a 
scrofulous disposition, showing itself along the edges of the eye- 
lids. The hair-follicles are involved with small pustules which 
are succeeded by crusts. The parts are generally swollen, red, 
and itchy, and, unless frequently cleansed, tend to glue together. 
Conjunctivitis may or may not be present. The local treatment 



216 INFLAMMATIONS. 

must vary according to the intensity of the disease. If severe, 
the eyelashes may be extracted and the edges touched with a solu- 
tion of potassa in water, ten grains to the ounce, as recommended 
by McCall Anderson. The edges should be carefully dried and 
the lid everted, a very small quantity on a delicate brush being 
applied. The alkali should be immediately neutralized with dilute 
acetic acid or vinegar. The operation may be repeated every few 
days, after which a weak ointment of the nitrate of mercury may 
be used. In mild cases this ointment, weakened, may be em- 
ployed alone with good result. It is scarcely necessary to add 
that energetic internal treatment, with hygienic measures, is called 
for in almost all of these cases. 

Eczema Barbae. — When the disease attacks the region of the 
beard it gives rise to much disfigurement, pain, and annoyance, 
and is generally found to be stubborn in its course. It is char- 
acterized by the rapid and extensive formation of pustules, which 
are situated in preference around the hairs. Crusts of a yellow- 
ish or greenish color are soon formed, which, matting the hairs 
together, adhere to the parts. A portion only or the whole of 
the beard may be involved. The disease may run an acute course, 
but more frequently it takes on chronic action. It may be con- 
fined to the hairy portions of the face, or it may, and often does, 
extend to other regions of the face. In this respect it differs from 
sycosis non-parasitica, which is always limited to the hair-follicles. 
As regards the general features, these two affections are very 
similar, but the difference is in most eases sufficiently clear when 
the various points of distinction are carefully viewed. Sycosis is 
an inflammation of the hair-follicles only, — a folliculitis barbae, 
characterized by the formation of papules, tubercles, and pustules ; 
the process is a deep one, and is concerned with the follicles them- 
selves. In eczema the process is more superficial, and extends over 
the surface, involving the follicles in its course exactly as in eczema 
of the scalp. Papules and tubercles, common in sycosis, are want- 
ing in eczema of the beard. The general history of the case will 
aid in distinguishing the two diseases. 

Tinea sycosis also resembles eczema barbse ; but, remembering 
certain symptoms always found in the former affection, error can 
scarcely occur. Crusts are generally abundant in eczema ; in tinea 
sycosis, except in extreme cases, they are scanty. The crusts being 



ECZEMA. 217 

removed, the surface of the skin in eczema is smooth ; in tinea 
sycosis it is often uneven, lumpy, or tubercular. This point is of 
value in diagnosis. The hairs of eczema are not to be plucked 
without pain, for they are firmly seated in their follicles. In 
tinea sycosis they almost drop out of their own accord. The 
hairs themselves, examined either with the naked eye or with the 
microscope, are found to be different : in eczema they are straight, 
with a luxuriant-looking, glutinous mass — the root-sheath — at- 
tached to their roots, while in tinea sycosis they are crooked or 
twisted, and are usually dry. In eczema there exists no fungus; 
it is always present in tinea sycosis, and may readily be detected 
with the microscope. Eczema is not contagious ; tinea sycosis is 
highly so, and its source may, moreover, often be traced to tinea 
circinata, either upon other parts of the body or upon other mem- 
bers of the family. 

The treatment, to be effectual, must be energetic and decided. 
After the crusts have been taken off by means of poultices or warm 
water and soap, the part is to be cautiously shaved. The first 
operation is apt to be painful, but, after this, patients, as a rule, 
do not complain. The beard is to be kept clean, shaving being 
resorted to every other day, or as may be necessary. This is an 
important part of the treatment. The difficulty of bringing the 
remedies into immediate contact with the skin if the stiff hairs 
are permitted to protrude will be appreciated. If the process be 
acute, the method of treatment by means of unguentum diachyli 
and soap, either castile or sapo mollis, may be directed, the dis- 
ease being managed in the same manner as upon the non-hairy 
portions of the body. The applications may be employed con- 
tinuously, both day and night, or only at night. The parts should 
never be rubbed vigorously, or the soft soap applied, unless the 
ointment is to be afterwards bound on. In the chronic stage, 
stimulating ointments, such as a sulphur ointment, half a drachm 
or a drachm to the ounce, or a white precipitate ointment, fifteen 
or thirty grains to the ounce, are to be used. The prognosis is 
favorable, provided the patient is able to carry out the treatment 
faithfully ; but the cure, even under these circumstances, is often 
tedious. 

Eczema Aueium. — The ears are a frequent seat of eczema, in 
both children and adults, and may be involved in connection with 



218 



INFLAMMATIONS. 



the disease upon contiguous regions, or they may alone be attacked. 
The erythematous, vesicular, and pustular varieties all occur here. 
In the acute stage the ears become swollen and red, and are the 
seat of severe burning and itching. One or both may be attacked, 
more commonly both. The process often extends into the meatus, 
causing occlusion and temporary deafness. When there are ves- 
icles or pustules, crusts form and envelop the whole appendage ; 
in other cases there is thickening, with desquamation in the form 
of flakes or large scales. The meatus, when attacked, is usually 
affected in this latter manner. The diagnosis of erythematous 
eczema of the external auditory canal is often overlooked. 

On account of the peculiar anatomical structure of the ears, the 
successful application of remedies is difficult. Ointments will be 
found most serviceable. The preparations of tar are of particular 
value, and are usually tolerated after the acute stage has passed 
away. Calomel is also very useful, in the strength of half a 
drachm to the ounce. When the disease is located about the 
meatus, care is to be observed in the use of strong remedies, lest 
the application have an injurious effect upon the membrana tym- 
pani. The canal should be washed out by means of a suitable 
syringe, and cleansed of crusts and scales. A few drops of oil 
of sweet almond may first be introduced, to soften the mass. The 
u>e of potassa solutions, followed later by stimulating ointments, 
as suggested in the treatment of eczema of the eyelids, will some- 
times be found of service. If strong or caustic solutions are 
employed, care is to be exercised in protecting the drum and in 
counteracting the effects of the caustic. The disease is usually 
obstinate. 

Eczema Aeticuloeum.— Eczema generally selects the flexor 
surfaces for its seat : the axilla?, flexor surfaces of the elbow-joints, 
popliteal spaces, groins, are all favorite regions. The disease 
rapidly passes into the moist state, attended by maceration of the 
epidermis, which is kept up either by the motion of the parts or 
by the rubbing of opposite surfaces. The process is almost always 
symmetrical. In certain of the localities mentioned it passes into 
the condition known as eczema intertrigo, to be referred to. 

Eczema Genitalium.— These organs are frequently attacked, 
occasioning most distressing symptoms. In the male the scrotum 
and penis may be involved together, or either alone may be the 



ECZEMA. 219 

seat of disease, but the scrotum is the region commonly affected. 
Owing to the rich supply of lymphatics, it is apt to be consider- 
ably swollen and ©edematous. Moisture, crusts, and painful fissures 
are prone to occur, followed by extensive thickening. The itching 
is usually severe. It is an extremely harassing form of the disease, 
and is generally obstinate. The female organs suffer like symp- 
toms. The labia are usually affected, but the vagina "may also be 
invaded. The disease may further extend to the surrounding 
parts, including the mons veneris and perineum. When the labia 
are attacked they are swollen and generally ©edematous. They 
are bright or dark red in color, hot and inflamed, and ordinarily 
discharge freely from their surfaces; crusts form, and the opposing 
surfaces are apt to become more or less glued. At other times no 
discharge takes place, the parts being simply erythematous and 
slightly scaly. The itching is violent, and at times occasions in- 
tolerable misery. The causes of the disease in females are often 
to be referred to uterine disorder. 

Eczema of the genital organs in either sex at times yields easily 
to treatment, and in other instances is in the highest degree in- 
tractable. Upon the scrotum, the method by means of sapo viridis 
and unguentum diachyli will often be found to relieve the symp- 
toms when other means have failed. Potassa solutions, half a 
drachm or even a drachm to the ounce, may be applied in place 
of the soap. But these powerful caustics are never to be used 
without counteracting their effects by means of water or dilute 
acids; bland ointments, moreover, should always immediately suc- 
ceed their use. In the acute stage of the disease, lotio nigra may 
be recommended, to be followed by an ointment of oxide of zinc 
and calomel, half a drachm to the ounce. Carbolic acid, in the 
form either of lotion or of ointment, ten or fifteen minims to the 
ounce, is^an invaluable remedy in many cases. Thymol is also 
useful. Stimulating ointments, as the mercurials and tarry rem- 
edies, may be in turn tried, for it frequently happens that one 
preparation will answer when another of a similar kind fails in 
giving relief. Painting the part cautiously with tincture of iodine 
will sometimes prove useful. 

Eczema Ani. — The anus is frequently alone attacked ; in other 
instances the perineum and the genitalia are also involved. The 
part becomes red, infiltrated, and thickened, either with or without 



220 INFLAMMATIONS. 

fluid exudation. Fissures are generally present, and more or less 
pain consequently attends each movement of the bowels. The 
itching and burning are of a most persistent and annoying char- 
acter, and are generally worse at night. The disease is increased 
by the friction of the opposing nates, and by the heat, perspira- 
tion, and sebaceous secretion. Care should always be exercised in 
diagnosing between pruritus and eczema. In the former, it will 
be remembered, there exists no eruption, except that produced by 
rubbing and scratching. In eczema one or more of the charac- 
teristic symptoms will be present, and will aid in distinguishing 
between the diseases. The treatment is the same as that which 
has been directed for eczema of the lips. 

Eczema Intertrigo.— This has been spoken of when con- 
sidering eczema as it appears about the joints. It occurs upon the 
inner surfaces of the nates, in the groins, beneath the mamma?, 
and in other localities where folds of skin naturally come in con- 
tact with one another. A moist, macerated surface is the result, 
which is greatly increased by movement, walking, and inattention 
to cleanliness. It is oftenest met with during warm weather. 
Eczema of this description is not to be confounded with erythema 
intertrigo, or chafing, a hypersemic affection which is common in 
summer among people of all ages and classes. An erythema in- 
tertrigo, however, if neglected, may and often does pass into an 
eczema intertrigo. The parts should be washed with water, unless 
followed by some remedy, but seldom. Oxide of zinc, oleate 
of zinc, and starch dusting powders, with or without calomel, or 
astringent lotions, as of acetate of lead or acetate of zinc, a few 
grains to the ounce, may be used to advantage, the opposing 
surfaces being separated, and if possible retained in this position 
by means of lint or cloths. Boracic acid lotion, ten or fifteen 
grains to the ounce, with half a drachm of glycerine; and boracic 
acid ointment, a drachm to the ounce of vaseline, may both be 
referred to as valuable. Salicylic acid in the form of an ointment, 
fifteen grains (dissolved in alcohol) to the ounce, is also useful ; 
likewise salicylated starch, used as a dusting powder.* Complete 



* Kersch recommends that the starch be gradually mixed with a two or three 
per cent, alcoholic solution of the acid. Abstract in Dublin Jour. Med. Sci., 
Nov. 1881. 



ECZEMA. 221 

rest and attention to the treatment, will go far towards modifying 
the symptoms and relieving the affection. 

Eczema Mammarum. — The breasts in the female are at times 
the site of a stubborn eczema, which generally localizes itself in a 
circumscribed form about the nipples. One or both may be in- 
vaded. It is met with for the most part in women who are nursing, 
but it also appears in those who are not nursing, and in single 
women. It ordinarily assumes the vesicular form, soon becoming 
eczema rubrum, and is attended with crusts and extensive fissures. 
When exposed to the sucking of the child, pain is experienced, 
to such a degree that the mother is compelled to withdraw the 
infant either temporarily or permanently. The disease is always 
aggravated by nursing. The affection is encountered most fre- 
quently in primiparse. The nipples in severe cases become re- 
tracted, sink in the breast, and are covered with crusts. The 
diagnosis is not difficult, but the rnanimee, it will be remembered, 
are also usually affected in scabies. 

When practicable, the best and most expeditious treatment will 
be found in the sapo viridis and unguentum diachyli method, 
already described. The parts, though apparently tender and sensi- 
tive, will tolerate the free use of the. soap and friction in most 
cases, and after being properly dressed will feel greatly relieved. 
The applications may be made once or twice a day. The 
boracic acid and salicylic acid ointments, referred to on the pre- 
ceding page, will be found useful ; also the ointment of oleate 
of zinc. Before nursing, the nipples should first be anointed 
with olive oil, to soften the ointment, and then washed with 
soap and water. After nursing, the ointment may be reapplied. 
Unless treated vigorously, eczema of the breasts is apt to prove 
of a refractory nature. 

A rare obstinate affection of the skin of the areola and nipple, 
classed usually as chronic eczema of the nipple, is sometimes fol- 
lowed by cancer, as has been shown by Paget,* and more recently 
by Thin.f The latter observer proposes that the disease, which 
is peculiar, shall be termed "malignant papillary dermatitis," it 



* St. Bartholomew's Hospital Reports, 1874 

f Brit. Med. Jour., vol. i., 1881, pp. 760, 798. See also Munro's article, 
Glasgow Med. Jour., Nov. 1881. 



222 INFLAMMATIONS. 

being characterized by destruction of connective tissue. In dis- 
tinguishing it clinically from simple eczema, the chief points to 
be borne in mind, according to Thin, are the well-defined margin, 
and the evidence, when the disease is taken between the fingers, of 
infiltration in the papillary layer. The same observer states that 
the disease is duct cancer, developed from the epithelium of the 
lactiferous ducts, and not true scirrhus or parenchymatous cancer, 
which is developed from the secreting epithelium of the acini. 

Eczema Umbilici. — This is met with either alone or in con- 
nection with the disease upon other parts of the body. The navel 
itself may be the only portion involved, or the surrounding skin, 
in the shape of a circular patch, may also be affected. It is usu- 
ally moist and fissured. A disagreeable odor is generally con- 
nected with the exudation, and crusts form and adhere to the 
skin. The diagnosis is sometimes rendered difficult by the fact 
that syphilis attacking this locality often simulates eczema. Ul- 
ceration, however, will be encountered in syphilis, and the odor, 
moreover, will be offensive. The treatment will depend upon the 
variety of the disease present, upon the extent of skin involved, 
and upon peculiarities in the formation of the navel. An oint- 
ment of oleate of zinc, a drachm to the ounce, with fifteen or thirty 
grains of calomel, will often prove of value. 

Eczema Crurum. — The legs are among the most common lo- 
calities attacked, especially in old people, both male and female. 
Eczema here gives rise to a chronic condition which may last for 
years. It appears in the form of the erythematous and vesicular 
varieties, which, however, soon lose their distinctive features, pass- 
ing, as a rule, rapidly into eczema rubrum or eczema madidans. 
One or both legs may be affected. Other portions of the body are 
not, as a rule, assailed at the same time; patients may have eczema 
of one or both legs for a long period without showing any trace 
of the disease elsewhere. It is rare among young persons, but 
more common as age advances, while among middle-aged and old 
people, especially in dispensary practice, its occurrence is extremely 
frequent. It shows itself in the shape of one or more patches, 
varying in size, seated in preference upon the anterior surface of 
the limb. The patches, if small, ordinarily coalesce, and form one 
continuous patch, involving often the greater portion of the leg. 
When chronic, — the state in which it generally first comes under 



ECZEMA. 223 

notice, — the leg usually presents the following appearances. It 
may be deep red in color, covered in part or wholly with large, 
thick, yellowish or brownish crusts, discharging here and there 
between the crusts the ordinary fluid, either clear or mixed with 
pus and blood. In places the skin is laid bare, the result of 
scratching, and shows an inflammatory, punctate, oozing surface. 
On the other hand, the leg may be red, without moisture or crusts, 
exhibiting a smooth, shining or scaly, unbroken skin, in the form 
of patches, or, more commonly, one large patch. Both forms of the 
disease are, however, attended with infiltration, thickening, inflam- 
matory symptoms, and itching. Eczema crurum is frequently 
associated with varicose veins, this being a common origin of the 
disease. Ulcers resulting from the breaking down of these veins 
are often present, and complicate the condition. The diagnosis is 
rarely obscure. The hypertrophic state of the tissues known as 
elephantiasis Arabum is at times accompanied by eczema; the 
eczema here, however, will be recognized as being secondary to 
the original aifection. If varicose ulcers happen to be present, 
they are to be distinguished from syphilitic ulcers, which often 
show themselves in this region. 

The treatment will depend upon the variety, stage, and extent 
of the disease, and also upon the surroundings of the patient. In 
cases of moist eczema, the most successful plan of treatment is that 
consisting in the employment of sapo mollis and unguentum 
diachyli, already described. It is in these cases that the most 
favorable results follow this treatment, provided it be properly 
carried out. "Where the disease is not in a discharging state, other 
methods, involving less time and trouble, may be substituted, and 
often with equal success. The various remedies referred to in con- 
sidering the general treatment of eczema may all be prescribed, as 
may appear suitable to the case. A prescription containing calomel, 
half a drachm, oxide of zinc ointment, four drachms, and vaseline, 
four drachms, will be found serviceable for many cases, especially 
where the disease exists in discrete patches. It is necessary where 
there are varicose veins, or where there is tendency to swelling, that 
the limb be properly bandaged. The bandage should be applied 
both for the purpose of retaining the dressings in their place, and 
for supporting the leg and relieving the congestion. This will 
prove of comfort to the patient, and will materially hasten the cure. 



221 INFLAMMATIONS. 

Ulcers, when present, may receive the same management as the 
eczema. Of great value in the treatment of chronic eczema of the 
legs, especially when complicated with ulcers, is the india-rubber 
bandage, brought to the notice of the profession by Martin,* and 
later by Bulkley.f The bandages should be made of the best 
rubber, and should be thin and elastic. They are to be applied 
directly to the skin, the limb being first cleansed. As a rule, the 
bandage is worn only during the day. On removing it at night 
it should be washed and dried; the limb should be similarly treated, 
and enveloped in a muslin bandage or other cloth dressing for 
protection. In long-standing chronic eczema accompanied with 
thickening, oedema, or varicose veins, it will be found a most 
valuable method of treatment. There are some cases, however, 
in which this treatment does not answer, causing increased inflam- 
mation and the production of small pustules. A few clays will 
usually determine its efficacy or the reverse. 

Eczema Mandum. — Owing to the peculiar anatomical forma- 
tion of the skin about the hands, as well as to the exposure to 
which they are subjected, they are very frequently the seat of dis- 
ease. One or both hands may suffer; ordinarily both are affected. 
The feet may be attacked at the same time, though this rarely 
occurs. All of the varieties of eczema are encountered upon the 
hands ; erythema, vesicles, papules, and even pustules, are here 
seen in their typical form. Fissures, sometimes long and deep, are 
usual about the knuckles, and upon the palms and also the backs 
of the hands. They constitute annoying and painful lesions, and 
are hard to manage on account of the constant motion which is 
necessarily taking place. The hands are subject to acute as well 
as chronic eczema. All of the fingers are usually more or less 
involved, especially upon their lateral surfaces; in cases of vesic- 
ular eczema of the sides of the fingers the entire epidermis is at 
times undermined by fluid, forming in some cases small blebs. 
In connection with chronic eczema of the fingers, the nails are also 
frequently diseased. 

The causes of eczema of the hands are numerous. Chemists, 



* Trans. Araer. Med. Assoc, vol. xxviii. p. 589; Chicago Med. Jour., Oct. 
1877; Brit. Med. Jour., Oct. 26, 1878. 
f Arch, of Derm., July, 1878. 



ECZEMA. 225 

workers in alkalies or acids, bricklayers, bakers, grocers, cooks, 
and others, who have their hands continually exposed to the action 
of irritants, are liable to be attacked. Among the various sub- 
stances none act upon the skin more deleteriously than alkalies. 

As scabies always affects the fingers in preference, the diagnosis 
between eczema and this disease is sometimes extremely difficult. 
The presence of the parasites, as proved by the burrows, which 
are to be sought for on the lateral surfaces of the fingers, is at 
times necessary to determine the diagnosis. In eczema the vesicles 
are apt to be numerous, and crowded upon a given portion of the 
hand ; in scabies they are more scattered, and are found alike over 
all the fingers. The vesicles and pustules of eczema are small ; 
in scabies they are of variable size, and often large. The vesicles 
of eczema usually rupture shortly after they form, especially upon 
parts where the epidermis is thin ; in scabies they often remain 
whole until disturbed by scratching or other mechanical means. 
The vesicles of scabies commonly exhibit a fine, dark, irregular 
line, made up of points, through their summits, being the original 
burrow in the epidermis which has been raised by the forma- 
tion of the vesicle. The peculiar distribution of scabies over cer- 
tain regions of the body will, with the above features, generally 
enable the diagnosis to be made. Vesicular eczema of the hands 
may also be confounded with dysidrosis and pompholyx. 

Eczema of the hands and fingers is particularly intractable. 
The hands must be protected from all irritating influences ; they 
should be kept out of water, and the free use of soap prohibited ; 
exposure to heat should also be avoided. Rubber gloves will in 
some cases be found useful ; but in the majority of cases one of 
the stimulating ointments, as of calomel, white precipitate, or tar, 
will prove most serviceable. These may be used alternately with 
one of the milder ointments, as, for example, oleate of zinc, half a 
drachm or a drachm to the ounce. 

Eczema Palmarum et Plantarum. — Eczema presents the 
same features in both of these regions. Owing to the thickened 
state of the epidermis, it gives rise to peculiar lesions, which some- 
times obscure the diagnosis. Infiltration, thickening, callosity, 
dryness, and Assuring usually mark the disease. It is generally 
a chronic condition, and frequently lasts a long while. The fissures 
are often deep and so painful that the patient is unable to use 

15 



226 INFLAMMATIONS. 

Lis hands, or, if upon the soles, to walk. One or both palms or 
soles may be affected, either alone or in connection with other 
parts. At times, palms and soles are simultaneously attacked. 

The diagnosis is sometimes attended with difficulty, inasmuch as 
both psoriasis and syphilis are often localized upon these regions 
and may bear a close resemblance to eczema. Eczema differs from 
psoriasis in the following points. The fissures of eczema are apt 
to be slightly moist and bloody ; in psoriasis they are drv, and 
show but little tendency to bleed. The patches of eczema are 
generally larger and more diffused than those of psoriasis. In 
psoriasis the edges usually terminate abruptly ; in eczema they pass 
gradually into the healthy skin. The color of psoriasis is usually 
of a deeper hue than that of eczema. The scales, moreover, of 
psoriasis are whitish or grayish in tint, while in eczema they are 
more or less yellowish. The scales of psoriasis are also larger and 
thicker and more abundant than those of eczema. The itching is 
usually more marked in eczema than in psoriasis. The presence of 
either disease on other parts of the body will be sufficient to clear 
away doubt. 

Syphilitic manifestations frequently show themselves on the 
palms and soles, and must be distinguished from eczema. The 
infiltration of syphilis is of a firmer nature than that of eczema; it 
also extends deeper into the tissues, and gives the sensation of there 
being a compact deposit in the skin. Eczema is usually much 
more uniformly diffused than syphilis; the patches of syphilis are 
apt to be smaller and more circumscribed, and to have a tendency 
to spread on the periphery. Syphilis, as a rule, does not itch ; 
eczema does, though not always severely. In syphilis the line 
of demarcation between disease and health is generally sharply 
drawn. The history may be of some assistance in determining 
the nature of the lesion. 

The treatment is that of eczema rubrum, stimulating and strong 
remedies being, as a rule, demanded. Tar, calomel, white precipi- 
tate, and oleate of mercury are all useful. Four drachms of tar 
ointment, four drachms of vaseline, with half a drachm of calomel, 
will be found a serviceable formula. Oleate of mercury may be 
prescribed in the strength of from five to fifteen per cent, to the 
ounce of simple ointment. 

Eczema Unguium. — Eczema occasionally assails the nails. 



HEEPES. 227 

One or two or all may be affected. They are, however, riot often 
involved alone, but commonly in connection with eczema of the 
fingers. The disease is characterized by roughness, want of polish, 
unevenness, and a punctate or honey-comb appearance, which lat- 
ter sign, however, belongs also to psoriasis. The nail becomes de- 
pressed, particularly at its root, at which point its proper nutrition 
is arrested. The nail may remain in its diseased condition until 
by degrees it recovers, or it may be cast off and regenerated. 
Internal treatment, especially arsenic, is of greatest importance. 
Local treatment is to be directed to the root rather than to the 
nail itself. 

HERPES. 

Herpes is an acute, inflammatory affection, consisting of 
one or of several groups of vesicles, occurring for the most 
part about the face and genitalia. 

Symptoms. — It is often preceded and attended by slight symp- 
toms of malaise and pyrexia. Sometimes these symptoms are 
marked. It may occur either alone or in the course of a number 
of febrile diseases, as pneumonia, pleurisy, and the various fevers. 
The lesions usually appear in the form of a small cluster, and may 
coalesce ; they are few in number, rarely more than three or four. 
They are pin-head to split-pea sized, and contain at first a clear or 
cloudy watery fluid, which becomes somewhat puriform and desic- 
cates in small yellowish or brownish crusts. If rubbed or picked, 
an excoriation, usually superficial, takes place, which cicatrizes 
without leaving a scar. The appearance of the vesicles is gen- 
erally preceded by a feeling of heat in the region, together with 
sometimes swelling. The affection is apt to recur from time to 
time. It is an acute disorder, seldom having a duration of more 
than a week. There are two distinct regions in which herpes 
generally shows itself, from which circumstance the terms herpes 
facialis and herpes progenitalis have arisen. 

Herpes Facialis. — This may occur upon any part of the face, 
although it is commonly encountered about the lips, and especially 
the vermilion of the lips ; hence the name herpes labialis. It is 
frequently seen upon the alas of the nose ; more rarely it is observed 
upon other regions of the face, and on the auricles. The mucous 
membrane of the mouth, and the tongue, are also not infrequently 



228 INFLAMMATIONS. 

the seat of this form of herpes. Here the vesicles rupture early 
through maeeratiou, and therefore are seldom observed as vesicles, 
but rather iu the form of excoriated patches. Upon the lips the 
vesicles are usually small, few iu number, and confined to one 
cluster. The upper lip is more commonly affected. The lesions 
may either remain single or may coalesce, forming a vesicular 
patch, which terminates in a brownish crust. No ulceration takes 
place, and consequently no scars result, Herpes facialis is usually 
caused by some febrile or nervous disturbance of the system. It 
is seen in connection with slight digestive disorders and colds, and 
also attending more serious affections, as intermittent and typhoid 
fevers. 

Herpes Pkogexitalis — Upon the male this is observed 
chiefly about the prepuce, especially on the inner layer, which 
occurrence has given rise to the term herpes pr.eputialis. It 
may also occur upon the glans and upon the integument of the 
organ. According to Greenough, of Boston,* the parts most liable 
to be affected are the sulcus, the reflected mucous membrane of the 
prepuce, the glans, the margin of the prepuce, and the skin on 
the shaft, the regions being mentioned in the order of the fre- 
quency with which they are attacked. In the female it may show 
itself upon the labia majora and labia minora, and also upon the 
skin about the vulva. But the affection is rare in the female. 
It is essentially a disease of youth and early middle age. It is 
seldom encountered after the age of forty. The attack- is usually- 
preceded by a feeling of uneasiness, slight burning or itching, or 
neuralgic pain iu the part, accompanied by redness, congestion, 
and more or less oedema. This is soon followed by one or two or 
a small group of vesicles, more or less perfectly formed, seated 
upon an inflamed patch. The vesicles may or may not be accom- 
panied with marked areolae. The number of lesions varies. They 
are rarely less than two or three in number or more than ten or 
twelve. As a rule, from four to six are present, ^n size they 
vary from a pin-head to a small pea, and when multiple are apt 
to coalesce. They pursue a benign course, and, unless irritated, 
incline to heal in from one to two weeks. As a rule, only one 



* Archives of Dermatology, Jan. 1881. An admirable article on the sub- 
ject, read before the American Dermatological Association. 



HERPES. 229 

cluster is seen. The smarting and burning sensations are at times 
marked; in other cases insignificant. Sometimes pain is present, 
and it may be severe, involving the sacral plexus of nerves. 
Mauriac* has described such cases, which, however, might be 
more properly viewed as herpes zoster. The vesicles frequently 
run together and form small patches, which may become covered 
with a crust. Upon the inside of the prepuce and upon the inner 
surface of the labia the vesicles commonly break down and result 
in excoriations, which resemble superficial ulcers covered with a 
whitish deposit. Occurring here, the affection is liable to be mis- 
taken for one form or another of venereal disease. The lesions 
are occasionally very much like those of chancroid, and great care 
is in these cases necessary in order to make the correct diagnosis. 
The lesions of chancroid are seldom as numerous as those of 
lupus. The course of herpes, however, always enables the ob- 
server to come to a definite conclusion upon this point. A few 
days or weeks suffice to determine the question, for within this 
time herpes will have disappeared spontaneously, whereas a vene- 
real ulcer will have increased in size. The affection may also be 
confounded with erosions on the dorsum of the glans penis. It 
cau scarcely be mistaken for the initial lesion of syphilis. Where 
there is doubt, ample time should be allowed to pass before pro- 
nouncing positively upon the nature of the affection. Herpes 
progenitalis is exceedingly prone to recur repeatedly throughout 
life, and sometimes periodically. Its tendency to relapse is 
marked. With reference to this peculiarity, Doyon,f in an able 
monograph, considers the disease under the name of " relapsing 
herpes." Very frequently it will be found to have been preceded 
by the act of coitus. There are many who experience an attack 
after every coitus. Concerning the cause of the affection, it may 
be stated that the subjects of herpes progenitalis are apt to have 
previously suffered from one or more of the three chief venereal 
diseases, gonorrhoea, chancroid, and chancre. Greenough remarks 
that he has never seen a case where such was not the fact, and 
places gonorrhoea first in the list of causes. It would appear, 

* Lecons sur l'herpes nevralgique des organes genitaux. Paris, 1877. See 
also Bumstead and Taylor on the Pathology and Treatment of Yenereal Dis- 
eases, 4th ed., Phila., 1879. 

f L'herpes recidivant des parties genitales. Paris, 1868. 



230 



INFLAMMATIONS. 



therefore, that these diseases" leave the parts with a tendency to 
this affection, an analogy to which is found in the case of condy- 
lomata acuminata occurring about the genitalia. The origin of 
the disease must, I think, be viewed as local. It is oftenest en- 
countered in those with long prepuces, a condition which certainly 
predisposes to the affection. 

Treatment. — The lesions should be guarded from rupture and 
irritation, and a cerate or ointment, used to protect them from 
excoriation. Cleanliness, in the case of herpes progenitalis, is 
also important. Lotions consisting of dilute ammonia- water, of 
lead-water, of sulphate of zinc, five or ten grains to the ounce, or 
of glycerine, are often grateful. Washing the parts with a satu- 
rated solution of boracic acid, or with the solution of chlorinated 
soda and dusting with calomel, are both useful in herpes of the 
genitals. Borated cotton will also be found a valuable dressing 
for the lesions. As a prophylactic measure, circumcision, where 
required, may be practised. Astringent lotions, as of tannic acid 
or sulphate of zinc, may also be used with the view of rendering 
the parts less sensitive. 

Herpes Gestationk.— Under this name Milton,* Bulkley,f 
and more recently Living,]; Cottle,§ and W. G. Smith,|| have de- 
scribed a rare affection of the skin, peculiar to pregnancy, and 
which they regard as a variety of herpes. It consists in the de- 
velopment of erythema, papules, vesicles, and bullae, vesicles pre- 
dominating. They are attended with intense itching and burning 
sensations. They are commonly grouped, but do not follow any 
nerve tracts. The vesicles and bulla? vary in size; they may be 
pea sized or as large as a walnut. The lesions usually first appear 
on the extremities, and afterwards involve other portions of the 
body. It is an affection directly dependent upon the gravid state 

* The Path, and Treat, of Diseases of the Skin, p. 20-5. London, 1872. 

f Amer. Jour, of Obst. and Dis. of Women and Children, Feb. 1874. 

X Lancet, vol. i., 1878, p. 783. 

I St. George's Hospital Eeports, 1879. 

|| Dublin Jour, of Med. Sci., Jan. 1881. 

Wilson was the first to mention the disease. He speaks of it as " herpes 
circinatus bullosus." (Diseases of the Skin, p. 294. Lond., 1867.) Hardy, 
under the name of "pemphigus prurigineux," also mentions the affection.' 
(Lecons sur les maladies de la peau, p. 137. Paris, 1863.) 



HERPES ZOSTER. 231 

of the uterus. It may appear at any period of gestation up to the 
seventh month, and when present usually continues until after 
delivery. It does not terminate in its course immediately after 
delivery, but slowly retrogrades by the development of fewer and 
fewer vesicles ; it is apt to recur with succeeding pregnancies. It 
is at times accompanied by urticaria, neuralgia, and other neurotic 
affections. 

HERPES ZOSTER. 

Syn., Zona ; Cingulum ; Ignis Sacer ; Zoster; Shingles; 6?erm., Giirtel- 
krankheit ; Feuergiirtel ; Fr\, Zona. 

Herpes zoster is an acute, inflammatory disease, charac- 
terized BY GROUPS OF VESICLES SITUATED UPON INFLAMED BASES, 
ACCOMPANIED BY MORE OR LESS NEURALGIC PAIN. 

The disease generally commences by slight or marked neuralgic 
pains, which are experienced not infrequently for several days 
before any sign of eruption shows itself. Kaposi states that in 
rare cases these pains may exist for as long as from three to six 
weeks preceding the outbreak. They may be diffused over the 
whole of the region about to be attacked, or, on the other hand, 
localized to one or more points. Sometimes pain is altogether 
wanting. It is usually of a severe nature, and involves both the 
deeper and the more superficial structures of the region, and in 
a manner altogether disproportionate to the amount of eruption 
which follows. In severe cases febrile symptoms, more or less 
marked, are usually present. An inflamed condition of the skin, 
usually in the form of patches, is now observed, attended with heat 
and burning sensations, and groups of papulo- vesicles appear over 
the region. They soon become vesicles, and are of the size of pin- 
heads and small split peas, usually discrete, and are situated, as 
a rule, on a bright red highly-inflamed surface. They may be 
crowded together, when they are apt to coalesce, forming irreg- 
ularly-shaped patches. The vesicles continue to appear, one group 
after another, until from the fourth to the eighth or tenth day, 
when the eruption is usually at its height ; it stands in this con- 
dition for a few days, when it decreases, the vesicles drying up, 
until, at the end of two weeks or longer, nothing remains but 
dry, brownish crusts. These drop off in time, leaving, as a rule, 
scars, more or less pronounced, according to the severity of the 



232 INFLAMMATIONS. 



attack. The vesicles do not burst as in eczema, but remain intact 
throughout their course. They contain a clear yellowish fluid, 
which, as the disease declines, gradually turns thicker and becomes 
puriform. When at its height, the eruption is generally perfect 
in its anatomical characters, the vesicles being well shaped, fully 
distended, with translucent, yellowish contents, and seated upon a 
bright inflammatory patch of skin.* Some of the groups, how- 
ever, those that appeared first, are generally more fully developed 
than others; those that were last to appear, as a rule, do not become 
typically formed, so that the eruption may often be seen in its 
various stages upon the same individual/ The vesicles always 
tend to group, and are usually crowded together. The number 
of groups is exceedingly variable. Sometimes only a single group 
exists, while in other cases as many as four or eight may form. 
Where the disease is extensive, the groups may be so numerous 
and close together as to coalesce and form one or more large 
patches. In other cases they are more widely distributed, and 
sometimes are far apart. The disease runs an' acute course,' last- 
ing generally from ten days to three weeks or more, according 
to the severity of the attack, from its commencement to its ter- 
mination. ^ In severe cases, and especially where the disease is 
hemorrhagic, the duration may be much longer, sometimes as 
long as two or even three months. It is usually characterized by 
well-marked symptoms. 

Herpes zoster may also run an abnormal course, the above 
symptoms being only in part present. The vesicles may not be 
characteristic, appearing rather as abortive vesicles, or even as 
papules or papulo-vesicles ; on the other hand, small bulla* and 
pustules may occasionally show themselves. In severe zoster it is 
not uncommon for some of the lesions, or even groups, to become 
hemorrhagic (herpes zoster hemorrhagica), in which case 
they show a bluish-red or purplish color. Where the disease 
assumes a virulent type, especially in elderly persons, it may be 
followed by serious sequelae in the form of persistent and painful 
neuralgia, want of sensibility in the affected part, local paralysis, 
more or less atrophy of the muscles, and falling of the hair or 
teeth. Zoster of the orbital region is particularly liable to be 

* See my Atlas of Skin Diseases, Plate E. 



HERPES ZOSTEE. 233 

followed by sharp neuralgic pains, lasting sometimes for months 
or even for years, and later by anaesthesia: Sometimes the eye 
becomes involved, first as a corneal inflammation and secondarily 
as an iritis, the process occasionally terminating in loss of sight 
or even in death. There are also certain cases in which the whole 
process is checked in its course just as the distinctive symptoms 
upon the skin are about appearing. The neuralgic pain varies in 
intensity; at times it is slight, in other cases it is exceedingly 
severe. In children, in mild cases, it is often insignificant. In 
elderly adults or old persons it is usually sharp and often severe. 
As a rule, it is in the ratio of the age of the individual. The 
amount of eruption is seldom in any manner proportionate to the 
pain. 

The disease attacks various regions of the body, but has decided 
preference for certain parts. It is in almost all cases found upon 
well-known nerve tracts. There are, however, exceptions to this 
statement, where the origin of the disease would seem to be much 
nearer the surface, as shown by the distribution and by other 
symptoms. It is almost invariably confined to one side of the 
body. In rare instances, especially about the head and face, it is 
encountered on both sides. J. Jamieson* records a case of bilat- 
eral herpes zoster where the face, neck, and arms were all attacked 
simultaneously. Such cases are very rarely encountered. Accord- 
ing to the region upon which the disease shows itself, it is termed 

ZOSTEE CAPITIS, Z. FACIEI, Z. NUCH^E, Z. BEACHIALIS, Z. PECTO- 

ralis, z. abdomikalis, z. PEMOEALis. To express the precise 
locality invaded, other terms indicative of the anatomical regiou 
are also employed, as, for example, cervico-brachialis, dorso- 

PECTORALIS, CERVICO-SUBCLAVICULARIS, OCCIPITO-COLLARIS, 
DORSO-ABDOMINALIS, LUMBO-INGUIJSTALIS, LUMBO-FEMORALIS, 

sacro-ischiadicus, sacro-genitalis, etc. About the head, it 
is encountered both on the scalp and on the forehead (z. fron- 
talis). The eruption here usually makes its appearance on the 
course of the supra-orbital nerve, passing upwards over the scalp. 
The eye is liable to become involved (z. ophthalmicus), and the 
pain is sometimes very severe. There is generally injection of 
the conjunctiva, and sometimes inflammation of the cornea and 

* Australian Med. Jour., May, 1877. 



234 INFLAMMATIONS. 

iris, followed by profound disturbance of the organ. The ear 
may also be attacked (z. auricularis). The disease may also 
begin at the back of the head, spreading forward and occupying 
the whole side. The face alone, especially the cheek, may also be 
the seat of the disease; likewise the side of the neck, on a line 
with the second and third cervical vertebra, extending forward 
towards the larynx. In zoster brachialis the eruption usually 
first makes its appearance in the region of the lower cervical 
vertebrae, passing over to and down the arm to the elbow, or even 
farther. The flexor surface is commonly attacked. The chest is 
another region often involved, the lesions forming parallel with 
the ribs. The intercostal nerves here determine the track of the 
eruption. Zoster in this locality generally gives rise to great pain 
and difficulty in breathing; in its early stage the distress may 
readily be mistaken for incipient pleurisy. The: abdominal region, 
supplied by the lower dorsal and lumbar nerves, is very similarly 
affected. The two last-named regions are the most common local 
varieties of zoster, and have occasioned the name by which the 
disease is known. The disease also occurs on both the anterior 
and the posterior surface of the thigh, and on the buttock. It 
is also met with about the genitalia. It rarely occurs below the 
knee. 

The course of herpes zoster is always acute, though somewhat 
variable as to duration, terminating in recovery. The process is 
not infrequently attended by a certain amount of ulceration and 
subsequent cicatrices, which in severe cases may remain for life. 
The affection rarely occurs twice in the same individual.* Neu- 
ralgic pains are not infrequently present about the seat of the 
eruption long after all traces of the disease have disappeared. 
Sometimes, especially in elderly persons, they remain persistently 
for years. The disease is commoner in the winter than in the 
summer. It is met with in both sexes, and in children as well 
as in adults ; it is seen in the very young and also in the aged. 
From the statistics of the American Dermatological Association 
it appears that 262 cases were encountered out of 16,863 cases of 

* Kaposi reports a case where nine relapses occurred, all upon the right side 
of the body, hut not in exactly the same region. The case was in every way 
exceptional. TVien. Med. "Woeh., Nos. 25, 26, 1877; abstract in Lond. Med. 
Eecord, Nov. 15, 1877. 



HEEPES ZOSTEE. 235 

skin disease ; but the disease is of much more frequeut occurrence 
than these figures imply. 

Etiology. — The causes which occasion the disease are involved 
in obscurity, although clinical experience teaches that their nature 
may be quite different. It is, however, well recognized that in all 
cases the eruption is dependent upon a peculiarly irritable or in- 
flamed state of the ganglia or of the nerve trunks and branches. 
The cause producing this condition may be found in various influ- 
ences. Atmospheric changes, especially sudden cold, and exposure 
to damp winds or wet weather,, and the sudden checking of pro- 
fuse perspiration, have been observed to act as causes. Mechanical 
violence to a part, injuries to nerves, surgical operations, and un- 
usual exertion, have all been noted to give rise to the eruption.* 
Arsenic is supposed by some observers to be capable of causing the 
disease, — a view which was first brought forward by Mr. Hutch- 
inson, of London. Cases are certainly met with where it seems 
highly probable that the outbreak was due to this agent. Baren- 
sprungf was the first who considered the origin of the disease to 
be in the nerves, and that the inflammation was conducted through 
them to the skin. 

Pathology. — Barensprung, moreover, presented the view that 
the disease was one of the ganglionic system. He determined the 
primary seat of the affection to be in the spinal ganglia. In cases 
of zoster of the trunk he found the intercostal nerves thickened 
and injected, with their spinal ganglia softened and altered in 
structure, the inflammation always extending from the ganglia to 
the periphery. Danielssen J also demonstrated a marked reddened 
and swollen condition of an intercostal nerve, accompanied by an 
infiltration of the neurilemma. Weidner§ records changes not 
unlike those observed by Barensprung. Wyss|| gives an accurate 

* See Picaud's monograph, Des eruptions cutanees consecutives aux lesions 
traumatiques, Paris, 1875; also Mitchell, Injuries of Nerves, and their Con- 
sequences, Phila., 1872, p. 153. 

f Die Gurtelkrankheit, Charite-Annalen, Bd. ix. p. 114. Berlin. This 
paper is a valuable contribution to the subject. 

J Barensprung, loc. cit., p. 119. 

\ Berl. Klin. Woeh., No. 7, 1870. Archiv fur Derm, und Syph., 4 Heft, 
1870. 

|| Archiv der Heilk., iv. u. v., 1871. Archiv fur Derm, und Syph., 3 Heft, 
1872. 



236 INFLAMMATIONS. 

description of the changes encountered in a case which died in the 
early stage of zoster involving the eye and forehead. The first 
branch of the trifacial nerve was seen to be broader, thicker, and 
softer than that of the opposite side of the body, and had a reddish- 
gray color. The individual nerve bundles were separated by a 
reddish-gray, soft tissue containing numerous vessels. The nerve 
was surrounded by an extravasation of blood along its course from 
the orbit to the ganglion Gasseri, this body being considerably larger 
and softer than normal. It was, moreover, not yellowish-white, but 
bright red in color. The nerve was healthy at its origin from the 
brain, but was seen to become diseased as it entered the ganglion, 
and to contain numerous small blood extravasations. The accounts 
given by these and other observers of the pathological conditions 
agree with the more recent studies of Kaposi.* The disease, how- 
ever, is not in all cases due to inflammation of the ganglia. It 
may also have its origin at any point along the course of a nerve, 
and not infrequently originates in the peripheral distribution of 
the nerve. It may also be due to disease of the spinal cord and 
perhaps the brain, which, as Kaposi states, would account for 
bilateral zoster and for the reported cases observed after poison- 
ing by carbonic oxide gas. 

The microscopic examination of the skin shows the vesicles to 
have their seat in the lower strata of the rete. The papillae and 
coriuin are largely infiltrated with serum and with inflammatory 
cells. The vessels are enlarged, and the bundles of connective 
tissue more or less separated. f The observations of BiesiadeckiJ 
and Haight§ may be referred to. They have demonstrated that 
the vesicles are formed in the same manner as in eczema. Bie- 
siadecki found the papilla? considerably increased in size and filled 
with new cells, which penetrated into the coriura and even into the 
subcutaneous tissue. The bloodvessels of the papilla? were enlarged 
and distended with blood. Numerous spindle-shaped cells were 
seen to come out of the papilla? and to force themselves into the 



* Path. u. Ther. der Hautkrankheiten, 2te Auflage, p. 322. "Wien, 1882. 

f See also an interesting report by Kaposi on the pathology of the disease, 
Wien. Med. Jahrb., 1876, erstes Heft; abstract in Lond. Med. Record, April 
15, 1876. 

I Beitrage zur Phys. und Path. Anat. der Haut, p. 245. Wien, 1867. 

I Sitzungsb. der Kais. Akad. Wien, 1868. 



HERPES ZOSTER. 237 

mucous layer, separating themselves freely, so that the epithelial 
cells were compressed and made to assume the form of narrow 
perpendicular bands. Haight found numbers of round, nucleated 
cells in and around the neurilemma; they were probably pus 
cells. He also discovered the nerves to be swollen, the medullary 
substance softened, and the axis cylinder eccentrically increased in 
size. 

Diagnosis. — The characters of herpes zoster are usually so well 
marked that no trouble should arise in the diagnosis. The pre- 
monitory symptom of neuralgic pain iu the part about to be the 
seat of the eruption must point strongly to this affection. The 
appearance of the vesicles, in distinct groups, upon highly inflam- 
matory bases, and the tendency to preserve their form intact, are 
characteristic. The vesicles are larger than those of eczema, vary- 
ing in size from a pin-head to a split pea. The lesions of eczema, 
moreover, always rupture, and ooze forth a fluid which rapidly 
forms crusts; in zoster there is no discharge. The subjective 
symptoms of zoster are decided pain, seldom absent, and a burning 
sensation; in eczema there is positive itching. „ 

Erysipelas should never be confounded with herpes zoster. The 
line of demarcation about erysipelas, the deep-reddish color of 
the inflammation, and the constitutional symptoms, together with 
the absence of grouped vesicles and of neuralgic pain, will serve 
to distinguish it from zoster. 

Herpes zoster is to be diagnosed from the simple form of herpes 
seen about the face and genitalia, chiefly by the presence of pain 
and the tendency it has to occur once only in a lifetime. Simple 
herpes inclines to repeated attacks in the same individual. It also 
for the most part confines itself to certain regions, as the lips, nose, 
and genitalia, localities where herpes zoster is not commonly en- 
countered. In simple herpes there is usually only one group of 
vesicles; in zoster several distinct groups ordinarily occur. Zoster 
is almost invariably unilateral ; simple herpes often shows itself 
on both sides or on the median line itself. 

Treatment. — It will be borne in mind that the affection runs an 
acute course, terminating in spontaneous recovery ; also, that the 
course is usually a benign one as regards the result, except in those 
cases where sensitive regions of the body, as the eye, are involved. 
Internal medication has not heretofore proved of much avail in 



238 INFLAMMATIONS. 

influencing the course of the eruption, although, according to Ash- 
burtou Thompson* and Bulkley,f we have a valuable remedy in 
the phosphide of zinc, which lias been recommended by the former 
of these gentlemen in doses of one-third of a grain, to be given 
at the commencement of an attack and to be repeated every three 
hours. It is said to control the pain and to abort the eruption. 
My own experience with the remedy in these cases is too limited 
to warrant the expression of an opinion ; in some cases, however, 
it has seemed to act well. 

General symptoms may be combated as they present themselves. 
' Saline laxatives or effervescing draughts may often be agreeable to 
the patient in the first stage of severe zoster. Opiates given at 
night are useful, and may generally be prescribed liberally. The 
subcutaneous injection of the sulphate of morphia is another valu- 
able method of relieving the pain. In severe cases a course of 
tonic treatment, consisting of large doses of quinine, iron, arsenic, 
or the mineral acid*, may be beneficially prescribed. External 
treatment is also of importance and value. The parts should be 
protected from the irritation of the clothes and from other exter- 
nal influences; the vesicles should not be punctured, but preserved 
as far as possible intact. Various dusting powders, containing 
camphor and morphia, may be employed, and the part covered 
with a bandage. Anodyne ointments, containing powdered opium 
and belladonna, may also be used. Lotions containing opium, 
belladonna, camphor, and carbolic acid, fifteen or twenty grains to 
the ounce, arc likewise to be recommended. I have lately used 
the fluid extract of grindelia robusta in the form of a lotion, in the 
strength of from half a drachm to a drachm to the ounce, with 
advantage. Painting the lesions with tincture of chloride of iron 
is well spoken of by Baudon,* and more recently by Lailler and 
Mercier.§ Flexible collodion with morphia, in the strength of 
ten grains to the ounce, is also of value. The disease may be 
most advantageously treated by the galvanic current. In many 
cases it proves a very valuable means of relief. The constant 
current will be found of most service, applied directly to the seat 

* Glasgow Med. Jour., Oct. 1874. 
f Arch, of Derm., Jan. 1876, p. 158. 
X Bull, de Therapeutique, t. lxiii. p. 75. 
\ These de Paris, 1877. 



HERPES IRIS. 239 

of the eruption and over the course of the nerves by sponge elec- 
trodes. I. have usually found from five to ten cells to be suf- 
ficient, the application being continued for fifteen or twenty 
minutes at each sitting, and repeated every day, or, if possible, 
twice a day. There is no doubt that both the pain and the erup- 
tion may often be arrested by the timely use of the current, and 
even after the disease is at its height ease will generally be ex- 
perienced from its application. The after-pains of zoster may 
also be treated by the same means. 

Prognosis. — A few weeks usually suffice for the spontaneous 
cure of zoster, although severe cases may linger a month or longer 
before disappearing. The prognosis will depend upon the gravity 
of the attack and upon the region invaded. Occurring about the 
head, the disease is usually severe, and the pain generally intense. 
Zoster of the orbital region may seriously involve the eye, and 
prove fatal. 

HERPES IRIS. 

Syn., Hydroa ; Herpes Circinatus ; Germ., Herpes Iris ; Fr., Hydroa Vesi- 
culeux. 

Herpes iris is an acute, inflammatory disease, character- 
ized BY ONE OR MORE GROUPS OP VARIOUSLY-SIZED VESICO-PAPULES, 
VESICLES, OR BLEBS ARRANGED IN THE FORM OF CONCENTRIC RINGS, 
ATTENDED, AS A RULE, BY THE DISPLAY OF VARIED COLORS. 

Symptoms. — The patches vary in size from a small coin to sev- 
eral inches in diameter, and are made up of a number of more or 
less distinct vesico-papules or vesicles, which arrange themselves 
side by side so as to form at times a complete ring. Sometimes 
blebs form. Two, three, or more of these rings exist as a series, 
extending outwards towards the periphery of the patch. In size 
the lesions vary from a pin-head to a split pea, or larger, and are 
discrete or confluent, more often the latter. In number the patches 
also vary ; two or three or a dozen may be present: Between the 
vesicles the skin is pinkish or reddish and somewhat raised above 
the surrounding skin. The vesicles contain a yellowish watery 
or somewhat puriform fluid, which, after a day or two, dries, 
forming a slight crust. The oldest vesicles, those in the centre, 
desiccate first, while new ones on the periphery are being pro- 
duced. 



240 INFLAMMATIONS. 

The affection first shows itself as one or more papules around 
a central point; these change into vesicles, assuming the shape 
of a circle. No sooner has one ring been completed than another 
is observed to appear outside and around it, and perhaps another 
one around this, until sometimes three or four may be distin- 
guished. Usually the original and central vesicles will have in 
a great measure disappeared by the time the last crop has formed. 
The general hue of the eruption is peculiar. The colors are varied 
and delicate in tint, and generally pervade the whole patch. It 
is from this circumstance that the affection has received the name 
iris. The colors of the rainbow, subdued in tone, may usually 
be observed at one time or another in the course of the disease, 
the red, yellow, and violet shades predominating. The disease is 
an acute one, and is characterized by the successive appearance of 
the patches. These continue to come out for from one to three or 
four weeks, when the process usually ends spontaneously. 

Certain regions of the body are attacked in preference; the 
backs of the hands and feet, and the arms and legs, are the parts 
commonly involved. Marked symptoms of general disturbance 
are rarely present at any time during the disease. Itching or 
burning sensations may exist; but they are seldom pronounced. 
The course of the affection, anatomically considered, may be ab- 
normal. Blebs may occur in the place of vesicles, or the vesicles 
may be confluent and form irregularly-shaped blebs. In other 
cases, the eruption may barely arrive at vesiculation. The con- 
centric arrangement of the successive crops of lesions may also be 
wanting, especially about the hands. The general features, how- 
ever, of the disease may usually be recognized. The disorder pos- 
sesses a tendency to recur in the same person. It is a rare disease. 
It is not contagious. 

Etiology. — Herpes iris occurs chiefly in the spring and autumn. 
It is observed in both men and women, but it is more common in 
children and young people than in adults. But little is known 
concerning its nature. There is, however, sufficient clinical proof 
to demonstrate that, although somewhat formidable at times in its 
appearance, it is usually a simple disorder. 

Pathology. — It undoubtedly bears the closest relationship to 
erythema multiforme. It is, indeed, to be viewed as but an ad- 
vanced stage or a modification of this disease. From the oppor- 



HERPES IRIS. 241 

tunities which I have had of observing its course, it seems to me 
clear that they are one and the same process.* The objective 
symptoms, however, are so peculiar, and of so different a charac- 
ter from those of erythema multiforme, as to warrant placing the 
affection among the forms of herpes rather than with the erythe- 
mata, particularly as the lesions are of a markedly herpetic nature. 
It is a benign inflammatory process. 

Diagnosis. — The presence of the vesicles serves to distinguish it 
from erythema multiforme. From herpes zoster it may be known 
by the absence of neuralgic pain and of burning. The distri- 
bution and arrangement of the vesicles are, moreover, altogether 
different. In herpes iris they are arranged in more or less per- 
fectly formed rings, one outside the other ; in zoster they are 
clustered or grouped irregularly. The regions attacked are, 
moreover, not the same ; the hands and feet are very rarely the 
seat of zoster. The affection is most liable to be mistaken for 
pemphigus. But the lesions are unlike those of pemphigus in 
their size, formation, and course, and in their arrangement. The 
peculiar coloring of a patch of herpes iris is, moreover, sufficient 
to distinguish it from pemphigus. It may also be confounded 
with impetigo herpetiformis. The arrangement of the vesicles, 
and the absence of marked itching, are sufficient to separate the 
disease from eczema. 

Treatment. — No method of treatment, in many cases, seems to 
have effect in arresting the course of the disease. Quinine, 
however, administered in full doses early in the attack, is some- 
times of value. Locally, the part should be protected from the 
clothing, and the vesicles kept intact, and dusted from time to 
time with a powder of oxide of zinc. If excoriations exist, oxide 
of zinc ointment may be applied upon a cloth and bound to the 
limb with a bandage. The disease may also be treated with 
astringent or sedative lotions, as in the case of acute vesicular 
eczema. 

Prognosis. — This is favorable. The patient may be assured 
that the eruption will soon disappear, usually in the course of a 
few weeks. Relapses, however, are to be looked for. In some 
cases these occur once or even oftener during the year. 



* See Erythema Multiforme, p. 154. 
16 



242 INFLAMMATIONS. 



MILIARIA. 



Syn., Miliaria Rubra; Miliaria Alba; Sudamina (Hebra) ; Licben Tropi- 
cus ; Prickly Heat. 

Miliaria is an acute, inflammatory disorder of the sweat 
glands, characterized by pin-point and millet-seed sized pap- 
ules or vesicles, attended by pricking, tingling, and burning 
sensations. 

Symptoms. — Miliaria may show itself either as a papular or as 
a vesicular eruption ; in many cases both papules and vesicles and 
intermediate stages are present, although usually one or the other 
form of lesion will predominate. The two varieties call for sep- 
arate description.* 

Miliaria Papulosa.— This variety, known as lichen tropi- 
cus and prickly heat, commonly commences with the forma- 
tion of numerous minute, acuminated, bright-red papules. The 
lesions are exceedingly small, pin-head and millet-seed in size, and 
very slightly raised above the level of the skin. They occur in 
great numbers; are discrete, although often crowded together; and 
are usually dispersed, without order in their arrangement or dis- 
tribution, over a considerable surface. They make their appear- 
ance suddenly, and are preceded by and accompanied with more or 

* Tbe disease is not to be confounded with " miliary fever," known also as 
tbe "sweating sickness," "sudor anglicus," or "English sickness," which 
first made its appearance in England in the autumn of 1486. By the end 
of the year it had spread over the whole of England, having caused the death 
of multitudes of people. It recurred in 1507, 1518, 1529, and 1551. The 
epidemics varied in intensity. The disease also made its appearance in Ger- 
many, Holland, Denmark, Sweden, and Norway. On the continent it re- 
ceived the name of "the great mortality." It disappeared completely for 
more than one hundred and sixtv years, reappearing in the beginning of the 
last century in France and Italy, and likewise in Germany, Austria, and 
Belgium. Epidemics have occurred frequently since, one in the autumn 
of 1880, on the island of Oleron, off the west coast of France, reported by 
Pvochard (Le Prog. Med., No. 10, 1881). It is of the nature of an ephemeral 
fever, characterized by no special symptoms except remarkably profuse sweat- 
ing and the exanthem. The sweating usually appears early in the attack, 
the eruption, which is identical with that of miliaria, seldom before the third 
or fourth day. The mortality differs in various epidemics. For a full account 
of the disease the reader is referred to Zuelzer's article in Ziemssen's Cyclo- 
paedia of the Practice of Medicine. 



MILIAEIA. 243 

less sweating. Vesieo-papules and vesicles are usually seen here 
and there between the papules, rendering the affection somewhat 
multiform as regards its lesions. 

Miliaria Vesiculosa. — In the place of papules, vesicles may 
form. They are very small, seldom being larger than pin-points 
and pin-heads. They are usually acuminated in shape, rising from 
the surface in the form of whitish or yellowish minute points. They 
are generally present in large numbers, thousands of them appear- 
ing upon one patch, as, for example, upon the abdomen, and are 
always discrete. The skin from which they arise is more or less 
inflamed; commonly it is of a bright-red color, owing to each 
vesicle being surrounded by an areola (miliaria rubra). The 
vesicles themselves, when recent, are transparent and contain a 
transparent fluid ; when older they are opaque and yellowish-white 
(miliaria alba). Owing to the multitude of the vesicles and 
their proximity to one another, they generally give the skin a yel- 
lowish cast. In addition to the presence of the vesicles, there is 
more or less general sweating. The eruption may show itself in 
patches here and there, or it may appear over the greater portion 
of the body. Its usual seat is the trunk, but it may also attack 
the face, arms, and lower extremities. It is commonly seen about 
the abdomen, the sides of the trunk, and the back. 

The vesicles run an acute course, drying up usually in a few 
days, and terminating in slight desquamation. They do not tend 
to rupture spontaneously. If scratched or rubbed, however, they 
break down and discharge their contents, which form into extremely 
small, yellowish crusts. Inasmuch as the fluid which they contain 
is never more than the minutest drop, the crusting is insignificant. 
The affection may either come to an end in a few days or it may 
continue in the form of relapses, new crops of vesicles appearing 
from time to time. Its duration will depend upon the nature of 
the cause. I have seen cases which lasted throughout the entire 
summer, and even far into the autumn. 

Either variety of the disease may attack all parts of the body, 
but certain regions, as the abdomen, chest, neck, and arms, are 
commonly invaded. The disorder makes its appearance suddenly, 
without premonitory symptoms, and quickly assumes its definite 
characters ; a few hours may suffice for its development. The 
process varies in intensity ; at times it is slight, in other cases it is 



244 INFLAMMATIONS. 

so severe as to be the source of much annoyance. It is apt to 
disappear and to reappear unexpectedly, often without apparent 
cause. The taking of food or of hot drinks is frequently a suf- 
ficient cause to aggravate it, or even to produce an outbreak when 
there is a disposition to its manifestation. Both varieties are 
attended by tingling, pricking, burning sensations, which are at 
times distressing. 

Etiology. — It is caused by excessive heat. This may be pro- 
duced as the result of injudicious and superfluous clothing, or in 
consequence of a high external temperature. It is very frequently 
encountered during the summer months in various climates, espe- 
cially upon the sudden advent of unusually warm weather.* The 
papular variety is very common in the tropics, — hence the name 
lichen tropicus, — where it is a much more highly developed and 
serious disorder than with us. It is usually met with in fleshy 
persons, who perspire profusely, and in children. Those who have 
had it once are liable to repeated attacks. Too much clothing, 
flannel or other irritating wear, tightly-fitting under-garments, and 
bandages, arc all to be regarded as exciting causes. The vesicular 
variety, on the other hand, according to my experience, inclines to 
manifest itself in weak and debilitated subjects rather than in the 
strong or stout. It is not rare to meet with it in poorly-nourished, 
feeble, puny infants and young children, especially in summer, 
although it is also seen upon these at other times of the year. 
The superfluous under-clothing with which infants are so often 
burdened is the cause of much miliaria. In adults I have also 
observed it in those who were suffering from ill health, nervous 
prostration, severe dyspepsia, and general debility. 

Pathology. — The pathology of the two varieties of miliaria is 
the same : they are both inflammatory disorders of the sweat 
glands. In one variety the process inclines to the formation of 
papules, which have their seat about the orifices of the excretory 
ducts; while in the other variety the disposition is to vesiculation. 
The line separating these lesions, however, is in many instances 
but ill defined, and in consequence there results a mixture of pap- 



* In this connection an interesting paper " On Certain Prevalent Skin Dis- 
eases of the Summer of 1876," by Dr. E. B. Bronson, may be consulted. 
Arch, of Derm., Jan. 1877. 



MILIARIA. 245 

ules and vesicles. The process, viewed in its totality, inclines to 
vesiculation. It may be aptly compared to that which frequently 
takes place in eczema, where papules and vesicles are produced 
side by side, differences in individuals accounting for the mani- 
festation of one or the other lesion. Another instance may be 
cited in acne, papular miliaria being to vesicular miliaria what 
papular acne is to pustular acne ; they are merely varieties or, in 
some cases, stages of the same process. Congestion, followed by 
slight exudation, takes place about the ducts with great rapidity, 
and in a short time gives rise to the minute papules or vesicles, 
as the case may be, which remain until the cause producing them 
has been modified, when they quickly undergo absorption. 

Diagnosis. — No difficulty should arise in recognizing miliaria, 
when the nature and seat of the affection are taken into considera- 
tion. The papular variety possesses such peculiar symptoms, and 
is, moreover, a form of disease so common and well known, that 
it can scarcely be confounded with other affections. It is produced 
alone by unusual and sudden heat, and consequently is to be looked 
for, as a rule, only during warm weather. It may be diagnosed 
from eczema papulosum, the disease for which it is most likely to 
be mistaken, by its history, course, and subjective symptoms. The 
papules of eczema, moreover, are larger, more elevated, and firmer 
than those of miliaria. It makes its appearance suddenly, it may 
be in an hour's time; eczema, on the other hand, manifests itself, 
in comparison, slowly. It may continue hours or days, disappear- 
ing usually in as rapid a manner as it came. Removal of the 
exciting cause — heat — tends to relieve the condition, and often to 
dispel the affection completely. 

The vesicular variety is to be diagnosed from sudamen by the 
presence of inflammatory signs. (See p. 145.) The same kind of 
difference exists between sudamina and vesicular miliaria as be- 
tween comedo and acne. The presence or absence of inflammation 
gives one or the other disease. Sudamina and miliaria, it will be 
understood, are separated from each other upon purely anatomical 
grounds, as, for example, is done also in the case of erythema iris 
and herpes iris, and in other diseases. It is not to be confounded 
with vesicular eczema, to which it frequently bears a close resem- 
blance in appearance. The history of the disorder, its sudden 
advent, the accompanying state of general perspiration, together 



246 



INFLAMMATIONS. 



with the peculiar pricking and burning sensations, will usually be 
sufficient to distinguish it. In miliaria each vesicle is observed, 
when sufficiently isolated, to be surrounded by an areola; in eczema 
the whole surface is more or less uniformly inflamed. The local 
disturbance is generally much greater in eczema than in miliaria. 
Miliaria is apt to come and go from day to day, in the form of 
repeated acute attacks; eczema usually runs a progressive and 
definite course. Finally, the vesicles of miliaria do not rupture 
spontaneously; those of eczema almost always do. I consider 
this a characteristic feature, one which clearly separates the two 
diseases. Where eczema, however, supervenes, as it may do, upon 
vesicular miliaria, the case at once is altered ; in this event we 
have all of the symptoms common to vesicular eczema, and the 
affection is no longer to be regarded as a miliaria. The erup- 
tion of scarlatina is at times complicated by the appearance of 
vesicular miliaria, producing an erythematous, minute vesicular 
and pustular affection. The diagnosis here is apt to be diffi- 
cult, especially so if the constitutional symptoms of scarlatina be 
slight. 

Treatment. — The management of miliaria is usually simple. 
Active measures tend to increase rather than to improve the con- 
dition. Irritating washes and all ointments should be avoided, 
for their employment favors the development of dermatitis or 
artificial eczema. All precautions for the relief of the sweating 
are to be instituted. With lower temperature the glands cease 
secreting excessively; whereupon the condition, in the majority 
of cases, tends to subside spontaneously. The use of refrigerant 
diuretics, as the citrate, nitrate, or acetate of potassium, well 
diluted, will be found of decided value. In the case of the pap- 
ular variety, the removal of the cause, a cool apartment, absolute 
rest, light clothing, plain food, acidulated drinks, and saline 
laxatives will ordinarily insure speedy relief. In the vesicular 
variety, where new crops of the vesicles continue to appear, con- 
stitutional remedies of a tonic character, such as quinine and iron, 
may be prescribed. 

The local treatment is of very decided value. Absorbent dust- 
ing powders, consisting of lycopodium or of equal parts of oxide 
of zinc and starch, will be found most useful; they should be 
applied freely and frequently. Mild astringent lotions, such as 



MILIARIA. 247 

are useful in hyperidrosis, may be employed in obstinate cases ; 
lotio nigra, fluid extract of grindelia robusta, freely diluted, lead- 
water, and like remedies, dabbed upon the parts from time to 
time, will be of service. A solution of sulphate of copper, ten 
grains to the ounce, used as a lotion, is a remedy much employed 
in India for the relief of the papular variety of the disease. Al- 
kaline baths or lotions may also be used with benefit. The patient 
should be warned against rubbing or scratching the skin, for if 
this be indulged in the disorder may become greatly aggravated. 
Under judicious treatment the complaint usually disappears in a 
short time. Where there is a disposition to a return of the affec- 
tion, prophy lactic measures are to be practised for some time after 
the attack lias passed away; relapses are common. No fears need 
be entertained concerning danger from retrocession ; the sooner 
the disorder disappears, the better for the comfort of the patient. 
Prognosis. — In our climate the disorder is seldom obstinate. If 
neglected, however, it may pass into dermatitis or into eczema. 
It is most rebellious in fleshy persons, occurring about the natural 
folds of the skin, where it necessarily resolves itself into an erythe- 
matous or eczematous intertrigo. In children, also, it is a source 
of discomfort. It is liable to relapse in successive years. 

Dysidrosis, — Pompholyx. — Under the name of dysidrosis 
Tilbury Fox* described a more or less inflammatory disease, charac- 
terized by peculiar vesicles and blebs and an excoriated state of the 
skin, with maceration and exfoliation of the epidermis. It consists 
at first of minute, isolated, vesicular points, which are deeply em- 
bedded in the skin. They do not incline to rupture. After they 
have existed for several days, they increase in size and assume a yel- 
lowish color, and now resemble small boiled sago grains implanted 
in the skin. As the process advances, the vesicles become more 
distended, and elevated above the level of the surrounding skin, 
finally coalescing, and forming, in severe cases, small or large, 
irregularly-shaped blebs, showing no disposition to break and dis- 
charge. In the course of some days the fluid is poured out or 
reabsorbed, the epidermis desquamating and leaving an abraded 



* Skin Diseases, p. 476. New York, 1873. Also Brit. Med. Jour., Sept. 27, 
1873. 



248 



INFLAMMATIONS. 



surface. The affection, primarily, is not, as a rule, attended with 
marked inflammatory signs. It occurs upon various regions of 
the body, with preference for the hands and feet. In its slightest 
form it is usually confined to the hands, occurring especially upon 
the sides of the fingers and over the palm. One or both hands 
may be attacked. After the affection has existed for a while, the 
epidermis becomes macerated and sodden and the skin is apt to be 
sore and painful. In severe cases, according to Fox, the eruption 
may extend itself over the backs of the hands and over the arms, 
resembling the course of an eczema. The complaint is generally 
accompanied by itching or burning, which may be slight or severe, 
according to the extent and gravity of the case. It may continue 
weeks or months. Eelapses from time to time are the rule. Those 
who suffer from the disorder are generally the subjects of nervous 
debility, weakness, dyspepsia, and other depressing conditions. It 
may be mistaken for vesicular eczema. The treatment is to be 
directed against the general condition of the patient. The local 
remedies referred to in considering acute vesicular eczema may be 
employed. The affection is rare in this country. 

Much confusion exists as to the nature of the disease. The 
disorder, according to Fox and Crocker,* has its seat about the 
sweat glands, and consists in an undue distention of the sweat duct 
throughout its entire course, followed by a collection of the fluid 
within the skin. On the other hand, Mr. Hutchinson and Dr. 
Robinson have likewise described the disease in similar terms, but 
claim that it is in no way connected with the perspiratory appa- 
ratus, and designate it cheiro-pompholyxf and pompholjxj on 
account of the disposition to appear in the form of blebs, resem- 
bling at times pemphigus : neither of these observers, however, 
regards the affection as related to pemphigus. They consider it a 
neurosis. It is not improbable that two distinct diseases have been 

* Trans, of the Path. Soc. of London, 1878. 

f An excellent portrait of this disease may be found in Mr. Hutchinson's 
Illustrations of Clinical Surgery, Fasciculus III., Plate X. London, 1876. 

X Dr. Piobinson has mad&a careful clinical and microscopical study of the 
disease, which he regards as identical with the dysidrosis of Fox, and suggests 
the name of pompholyx as being more appropriate than cheiro-pompholyx. 
For further information on the subject the reader is referred to this article. 
Arch, of Derm., vol. iii. No. 4, 1877. 



PEMPHIGUS. 249 

confounded ; and it is only by such an explanation that I can 
account for the discrepancy of the views put forth. I have from 
time to time encountered a slight form of a vesicular non-inflam- 
matory disease attacking the hands and fingers, which I have 
always regarded as being due to disorder of the sweat apparatus. 
This affection, trivial and rare in my experience, I consider a 
mild form of the dysidrosis of Fox. I am also familiar with the 
cheiro-pompholyx of Mr. Hutchinson, two well-marked examples 
of which have within the year been under my observation, but 
cannot view this affection as in any way connected with the sweat 
glandular apparatus, or with the disease heretofore regarded by 
me as dysidrosis. Additional cases and further study are de- 
manded before deciding upon its nature and place in classification. 

PEMPHIGUS. 

Si/yi., Germ., Pemphigus; Blasenausschlag ; Fr., Pemphigus. 

Pemphigus is an acute or chronic, inflammatory disease, 
characterized by the formation of a succession of rounded, 
irregularly-shaped blebs, varying in size from a pea to an 

EGG. 

Symptoms. — There are two varieties of pemphigus, presenting 
symptoms so different in character as to call for separate descrip- 
tion. They are named pemphigus vulgaris and pemphigus foli- 
aceus. The former of these is the variety commonly encountered, 
and is to be regarded as the type of the disease. 

Pemphigus Vulgaris. — The disease may attack all portions 
of the body, and shows a marked tendency to appear without 
regularity of distribution over the whole surface, no part being 
exempt. It is most common, however, upon the limbs. It may 
also attack the mucous membrane of the mouth and vagina. The 
lesions are blebs from the commencement to the end, and possess 
marked features. They form slowly or rapidly : at times in the 
course of a day. Their number may vary from several to dozens; 
usually a half-dozen or more may be seen at any period during 
the attack, while at other times much larger numbers occur. In 
size they vary from a pea to a walnut or a goose's egg ; various 
sizes may generally be observed in a given case.* In form they 

* See my Atlas of Skin Diseases, Plate II. 



250 INFLAMMATIONS. 

are usually rounded or ovalish, and are elevated in a prominent 
manner above the level of the surrounding skin, at times as 
high as an inch. Their walls are generally fully distended with 
fluid, giving them the appearance of being stretched. They rise 
abruptly from the sound skin with a definite line of demarcation. 
In color they are yellowish, the fluid becoming cloudy or puri- 
form as they grow older. Sometimes more or less hemorrhage 
occurs, giving the lesions a streaked or a distinctly reddish or 
bluish color. They seldom rupture spontaneously. They incline 
to no particular arrangement, but appear here and there, either 
singly or together; occasionally, according to Hebra, they tend to 
cluster.* But little inflammation attends them, their bases being, 
as a rule, alone reddened; the surrounding skin is seldom erythe- 
matous. Each bleb runs its course in from two or three to six 
or eight days. A characteristic symptom of the lesions consists in 
their successive appearance. A crop of them no sooner disappears 
than others show themselves, and it is in this way that the disease 
runs its course. Itching and burning occur, as a rule, only slightly, 
the first of the symptoms being usually the most notable. At 
times, however, both of these sensations may be present in a 
marked degree, occasioning great distress (PEMPHIGUS prurigi- 
nosus). Pemphigus in the adult, as a rule, is attended by gen- 
eral disturbance of the system only in severe cases, and in unusual 
forms of the disease. In children, however, there is always more 
or less fever and constitutional derangement. 

The affection may be either acute (pemphigus ACUTUS) or 
chronic (pemphigus CHBONICUS), the latter course being the usual 
one. Acute pemphigus, indeed, is exceedingly rare, except in 
children, where it generally runs its course in two or three weeks. 
Pemphigus in the adult has an essentially chronic course, often 
lasting years. The disease usually attacks infants in the form 
of an epidemic. Such have been reported by Hamolle,f Barthel,| 
Padosa,§ and others; but it is questionable whether certain of 

* See Hebra's Atlas of Skin Diseases, Lief. IX., Tafel 7. 

f Gaz. Hcbdom , Nov. 13, 1874 ; abstract in Arch, of Derm., Jan. 1875. A 
report of a similar epidemic in the Lying-in Hospital at Leipsic, from Archiv 
fur Gynaekologie, may be found in the London Medical Record, June 3, 1874. 

X St. Petersb. Med. Woch., No. 1, 1876. 

\ Giorn. Ital. d. Mai. ven. e d. Pelle, xi. (1876) p. 30. 



PEMPHIGUS. 251 

these cases at least should not be regarded rather as examples of 
impetigo contagiosa. 

The disease may be benign or malignant, according to the con- 
dition and health of the patient, hygienic surroundings, diet, and 
other causes which tend to influence the type of diseases in general. 
Malignant pemphigus (pemphigus malign us) is characterized 
by the great size and number of the blebs. They form rapidly, 
coalesce, rupture, and are succeeded by excoriated surfaces, which 
not infrequently take on ulcerative action. Blood may also be 
poured out, which, in connection with a puriform exudation, col- 
lects upon the skin in the form of crusts. The patient's health 
is always seriously impaired in these cases. Itching and burning 
may be present in a remarkable degree. If the individual be 
cachectic, the disease inclines to an unfavorable termination (pem- 
phigus CACHECTICUS, PEMPHIGUS GANGRJENOSUS). 

Pemphigus Foliaceus. — Here the blebs differ from those of 
pemphigus vulgaris in that they are not distended or tense. They 
are, on the contrary, flaccid and only partially filled with fluid, 
which seems rather to undermine the epidermis than to uplift it 
into blebs. This imperfect formation of the lesions constitutes the 
chief peculiarity of the affection. They rupture before arriving 
at a state of full development ; or, the epidermis may be so readily 
detached from the true skin that large, loose, half filled, irregu- 
larly-shaped blebs are formed, which soon collapse and rupture. 
They may, moreover, coalesce, thus involving a considerable sur- 
face. Usually the greater portion of the body is attacked, and 
sometimes the whole surface.* The blebs succeed one another with 
rapidity and persistence, the same regions, moreover, being the 
seat of repeated attacks. In this manner large numbers are con- 

* I recall the ease of a man, some forty years of age, and otherwise in ap- 
parently perfect health, who was afflicted with this variety of the disease in 
its universal form. There was not a square inch of healthy tissue upon his 
surface, the fingers even heing affected. He was a patient in the Vienna 
General Hospital under the care of Professor Hebra. I noted the course of 
the disease, from time to time, for a year and a half, at the expiration of 
which period the man was still in a most distressing state. The continuous 
plain water bath, in which he lived for months, afforded him more relief than 
any other mode of treatment. In this country cases have been reported by 
Sherwell, Arch, of Derm., Jan. 1877; and by Graham, Canadian Jour, of 
Med. Sci., June, 1879. 



252 INFLAMMATIONS. 

tinually forming before the skin has had time to regain its normal 
state. The fluid dries immediately into thin whitish flakes, which 
are quickly detached and cast off in quantity ; beneath is seen an 
excoriated, red surface, — the rete and corium. When the disease 
has existed for a time, the skin presents a white, flaky appearance, 
the epidermis being loose, shreddy, and ragged. It has been well 
compared to a superficial scald. The process is invariably chronic, 
and may continue for years. Sooner or later the general health 
becomes seriously disturbed, profound prostration supervenes, and 
the patient may succumb. It is, happily, a very rare form of 
disease. 

Etiology. — Pemphigus is an uncommon disease. It is, I think, 
of less frequent occurrence in this country than in Europe. Ac- 
cording to the statistics of the American Dermatological Associa- 
tion, but 14 cases were encountered out of 16,863 cases of skin 
disease.* White, in Boston, reports having met with 15 cases 
out of 5000 consecutive cases of skin disease in dispensary practice, 
a large proportion of these having occurred in infants, f Accord- 
ing to my experience, the percentage in Philadelphia is, I think, 
even less. It is said to occur in all parts of the world. The causes 
are obscure. The disease is much more common in children thau 
in adults. After the period of infancy and childhood it occurs at 
all times of life with about the same frequency. Both sexes suffer 
in the same proportion. It occurs with equal frequency at all 
seasons of the year, and does not appear to be affected by atmos- 
pheric causes. Articles of food, as a rule, have no influence in 
its production, although a low and improper diet may determine 
the disease. The causes in most cases will be found in a low or 
depressed state of the general system. Not infrequently the ner- 
vous system is at fault. Mental depression has been observed to 
precede the disease. General debility, overwork, and nervous 
prostration are all to be regarded as productive of the disease. 
Serious menstrual disorder may prove a cause, and it has been 
noted to show itself first during pregnancy. The disease is not 
contagious. Syphilis is never a cause of the disease ; it, however, 
as is well known, occasionally gives rise to a bullous eruption 
resembling pemphigus, but with a different train of clinical char- 

* New York, 1879. f Bost. Med. and Surg. Jour., March 23, 1876. 



PEMPHIGUS. 253 

acters. The so-called syphilitic pemphigus (pemphigus syphi- 
liticus) is manifestly a bullous syphiloderm, and not a true 
pemphigus. 

Pathology. — The disease consists in the successive production of 
blebs, which, according to the observations of Simon and Hebra, 
differ in no respect, as regards their anatomical structure, from 
other blebs. Hebra* describes the mode of their appearance as 
follows. "Sometimes a circumscribed light-red spot appears, 
perhaps of the size of a bean or large coin ; this is paler in the 
centre, and may even present a tinge of white, indicating the 
point at which the bleb is to form, and from which it will spread 
outwards over the surrounding red surface. In other cases the 
spot, besides being red, is raised above the level of the surrounding 
skin, and in fact is at first a wheal, passing afterwards into a bleb. 
In other cases the bleb is not preceded either by a red spot or by 
a wheal, but begins originally as a small collection of clear fluid 
beneath the cuticle. Thus hyperemia of the skin may exist before 
exudation is poured out, or the latter may be formed before any 
congestion of the papillary layer is discoverable." The contents 
of the bulla? are yellowish or colorless, and consist of serum or, in 
later stages, of a puriform fluid ; blood is also occasionally present. 
The reaction is either neutral or alkaline. The older the fluid 
the more alkaline it becomes. The blebs, the urine, and the blood 
have all been submitted to chemical analysis, but without obtain- 
ing knowledge as to the more intimate nature of the disease. The 
relations of pemphigus to impetigo herpetiformis have been con- 
sidered by Heitzmann,f with the conclusion that they arise from 
analogous if not identical causes, and that they have to be con- 
sidered as kindred to each other. My own experience leads me to 
the same view. 

Diagnosis. — No difficulty should be experienced in the diagnosis 
of typical cases. It must be remembered, however, that the mere 
presence of blebs does not necessarily constitute pemphigus, inas- 
much as these are at times developed in other diseases, as well 
as by artificial means. But when their appearance together with 
their course is taken into consideration, and the fact that in pem- 
phigus they occur in crops, the diagnosis may usually be made. 

* Loc. cit., vol. ii. p. 388. f Arch, of Derm., Jan. 1878. 



254 



INFLAMMATIONS. 



So-called " pemphigoid eruptions," consisting of variously sized 
and shaped blebs, with or without peculiar features as to number, 
distribution, and course, are from time to time met with. They 
are for the most part obscure in their origin and nature, and 
are difficult of classification ; on account of their similarity in 
appearance in some cases to true pemphigus they are generally 
spoken of simply as above. As closely allied to and usually 
confounded with pemphigus, mention must be made of certain 
cases of so-called impetigo herpetiformis, or herpes impetigini- 
formis (Hebra), where blebs occur differing but slightly from 
those of pemphigus. 

Herpes iris sometimes bears a close resemblance to pemphigus. 
The following points of difference may be noted. Pemphigus in 
the adult is for the most part a chronic affection, continuing for 
months or years; herpes iris is always acute, running its course 
usually in a few weeks. In pemphigus full-sized blebs may 
always be noted ; in herpes iris the lesions are usually vesicles, 
which may attain the size of blebs. The varied colors which 
attend the vesicles and blebs of herpes iris throughout their course 
are absent in pemphigus, nor is the surrounding skin in this latter 
disease usually so inflamed. The vesicles of herpes iris are ar- 
ranged concentrically, and increase in this manner; the blebs of 
pemphigus incline to no such arrangement. The seat of the dis- 
ease in herpes iris — usually upon the arms, backs of the hands, 
and lower limbs — is characteristic; in pemphigus the disease has 
no seat of predilection. Impetigo contagiosa, especially in infants 
and children, may readily be confounded with the disease under 
consideration, and, as intimated, doubtless many cases of so-called 
acute pemphigus in children would in reality be found to be 
instanees of this disease. 

Scabies sometimes presents large vesicles and even blebs, but the 
general symptoms and course of the disease will always distinguish 
it from pemphigus. Pemphigus can scarcely be confounded with 
eczema. The bullous syphiloderm is to be diagnosed from pem- 
phigus by the fact that it dries into thick, bulky, greenish crusts. 
Beneath these crusts there exists an excoriation or ulcer, which 
secretes a greenish-yellow product mingled with blood. Other 
symptoms of syphilis (in children as well as in adults) may usu- 
ally be found in connection with the bullous syphiloderm, which 



PEMPHIGUS. 255 

will prevent error as to the nature of the lesion. The blebs of 
erysipelas can hardly be mistaken for those of pemphigus. ' 

It happens at times that blebs are produced by artificial means 
on the part of patients, for the purpose of feigning disease. The 
various stronger acids, especially nitric, dropped or painted upon 
the skin, cause these lesions to appear, at times, in a perfect 
manner.* Where such a cause is suspected, the patient should 
be placed under surveillance, when the deceit, if there be any, will 
readily be detected. 

Treatment. — Both internal and external treatment are of ser- 
vice, but especially the former, which must be directed against the 
cause. The case should first of all be attentively studied, after 
which the treatment determined upon should be rigidly enforced. 
Constitutional remedies are of the utmost importance in all cases 
where there is general impairment of the health, debility, and 
prostration. Functional disorders should be inquired after, and 
the various secretions carefully examined. Arsenic is by far the 
most valuable remedy which we possess for this disease. In most 
cases it acts very happily. Its employment should be persisted 
in. Hutchinson f considers it in the light of a specific. Quinine 
is also of value, especially in those cases in which the lesions are 
preceded by fever, and should be prescribed in full doses. Diet 
and hygiene should also receive due attention. In many cases 
there is a failure of accustomed health, which is to be restored 
only by proper nourishment and by attention to hygiene. The 
food should be of the best quality, and should consist of a full 
animal diet, including meat, eggs, milk, and cream. Cod-liver 
oil will also be found of value. Sherwell recommends linseed 
meal, in ounce doses, with milk, and reports two cases cured.| 
Wine or ale, in proper quantities, may likewise sometimes be 
directed with benefit. Rest, and freedom from mental distress, 

* A case of feigned pemphigus in a young girl, in Guy's Hospital, London, 
whom I was invited by Dr. Fagge to see, is called to mind. The blebs were 
numerous, and in appearance differed in no way from those of genuine pem- 
phigus. The artificial nature of the lesions was, however, suspected, and 
observation subsequently proved that they were produced by nitric acid. 

f See Med. Times and Gaz., vol. ii., 1875, pp. 461, 513, 565. A valuable 
contribution to the subject. 

X The use of linseed and linseed oil as therapeutic agents in diseases of the 
skin. Arch, of Derm., Oct. 1878. 



256 



INFLAMMATIONS. 



are to be secured, and, indeed, everything should be done to make 
the patient as comfortable as possible both in body and in mind. 

The local treatment should always receive attention, for in cer- 
tain rebellious cases this may for a time constitute the only means 
of affording relief. The blebs should be punctured and evacuated 
as soon as they have formed. Lotio nigra, liquor picis alkalinus, 
and the fluid extract of grindelia robusta, used as in eczema, may 
all be employed. A dusting powder composed of equal parts of 
oxide of zinc and starch, or somewhat stimulating dusting powders, 
as salicylated starch, serve as a useful dressing where the lesions 
occur over a large surface and in great numbers, and may be ap- 
plied after one or another of the foregoing lotions has been used. 
The bath also offers a most acceptable and beneficial method of 
treatment. It may be employed either as plain water or in con- 
nection with medicinal substances. In some instances the bran, 
starch, or gelatine bath affords relief. Hebra has used with bene- 
fit the corrosive chloride of mercury bath, in the strength of one- 
third of a grain to the pint of water; also potassa, in the form of 
a bath, in the strength of half a grain to the pint of water. The 
tar bath is also recommended. 

The best local treatment for grave cases is to be found in the 
continuous bath, as recommended by Hebra. This consists in 
permitting the patient to remain in a specially prepared bath-tub 
for days, weeks, or months, according to circumstances. In the 
tub are to be placed a horse-hair mattress and pillows, upon which 
the patient may rest comfortably. The water is to be kept suffi- 
ciently warm, and to be changed from time to time throughout 
the twenty-four hours. Patients will sometimes experience great 
relief from the bath. They may remain in the water, eating and 
sleeping and living there, for an almost indefinite period without 
in any way interfering with the general health.* There are cases, 
however, in which water does not appear suitable, or in which it 
is advisable not to use it. In these instances simple ointments 
may be directed, none being better than either the oxide of zinc 
or diachylon ointment, applied upon cloths and bound down to 
the part with bandages. 

* For a detailed account of the bath and its action, see Hebra 's work upon 
Diseases of the Skin, Trans, of the New Syd. Soc, London, vol. i. p. 320 ; also, 
second German edition of the same work (1874), yol. i. p. 273. 



LICHEN RUBER. 257 

Prognosis. — No disease runs a more arbitrary or uncertain course 
than pemphigus. Relapses are common. In adults the prognosis 
should always be considered with deliberation. Much depends 
upon the character of the blebs, their number, and the rapidity of 
formation. If they are flaccid, imperfectly formed, or hemorrhagic, 
and incline to rupture, the prognosis is unfavorable. When in 
large numbers, involving an extensive surface, and characterized 
by the rapidity and frequency of their formation, the result must 
in like manner be viewed with caution. Repeated febrile attacks, 
together with impairment in strength, point to a serious termina- 
tion. Opinion should in all cases be guardedly expressed, for the 
disease is one indicating severe systemic disturbance, and in grave 
cases may end fatally.* 

LICHEN RUBER. 

Lichen ruber is an inflammatory disease, characterized 
by pin-head or pea sized, plat and angular or acuminated, 
smooth and shining or scaly, discrete or confluent, red pap- 
ules, having a chronic, papular or papulo-sqtjamous course, 
attended by more or less itching. 

Symptoms. — The disease is one of the most peculiar of the pap- 
ular group, possessing features which serve to make the process 
distinctive. Two varieties are met with, viz., lichen ruber planus 
and lichen ruber acuminatus, the first of which is of much more 
frequent occurrence in this country than the latter. In lichen 
ruber planus the papules vary in size from a pin-head to a split 
pea; where several have coalesced, as occurs in the later stage, 
they exist in the form of small patches. In shape they differ from 
other papules, in that they are seldom round but are quadrangular 
or polygonal in form. They rise abruptly from the healthy skin, 
above which they are more or less elevated. They are flattened 
on their summits, and generally show slight umbilication with 
whitish puncta. To the touch they are firm. They have, in their 
early stage, a smooth surface, are free of scales, and have a glazed 
appearance; later, in those cases where the process runs into a 

* Fatal cases have been reported by Neumann, Allg. Wien. Med. Zeitung, 
No. 37, 1876 (abstract in Bost. Med. and Surg. Jour., Dec. 7, 1876), and by 
T. C. Fox, Med. Times and Gaz., vol. i., 1877. 
17 



258 



INFLAMMATIONS. 



papulosquamous stage, considerable desquamation may be present. 
In color they are dull pink, dull red, crimson, or even purplish, 
the tint varying with the individual, the age, and the locality. 
They are usually discrete, though when existing in numbers thev 
incline to coalesce and form patches. They also show a marked 
tendency to follow the natural lines and elevations of the skin, 
thus forming longer or shorter rows or bands of eruption. When 
they run together they lose the characteristics of papules, and 
assume the appearance of slightly elevated, flattened, more or less 
uneven patches of infiltration.* In lichen ruber acuminatus, as 
has been pointed out by Kaposi,f the lesions are smaller, pointed, 
and scaly. They show no disposition to group, and incline to 
spread rapidly. This form of the disease is very rare in this 
country. A case has been reported by Dr. White, of Boston.! 
Cases manifesting intermediate lesions are also not infrequently 
encountered. Both varieties may, moreover, occur together. 

The disease may show itself either in the form of localized areas 
or as a diffused eruption, involving a large portion of the surface. 
The localized form is that more usually met with in this country. 
Here the lesions are generally flat, and consist of one, two, or more 
aggregations, which may exist either upon a limited extent of sur- 
face, as, for example, the forearm, or upon different regions of the 
body. They may be disseminated or closely crowded together in 
the form of a solid patch. The diffused form,§ with usually 
acuminate lesions, may occupy a part or the whole of the body, 
appearing either as numerous isolated patches or in the form of 
extensive sheets of eruption. When this takes place, the papules 
are, as a rule, small, pin-head in size, and scantily covered with 
minute, thin, whitish scales. This form of the disease, however, 
in this country not infrequently develops from the flat papule or 



* See a lecture on this variety of the disease, by the author, in the Philadel- 
phia Medical Times, April 27, 1878. Cases have also been presented before 
the New York Dermatological Society; see Arch, of Derm., 1877. A repre- 
sentation of lichen planus may be found in Tilbury Fox's Atlas of Skin Dis- 
eases, Plate 13 

f Wien. Med. Woch., Xo. 3-5, 1877. 

I Hosp. Gaz. and Arch, of fYm. Surg., Nov. 1877. 

I This variety of the disease constitutes the Lichen Ruber of Hebra, as 
first described by him, and is chiefly encountered in Austria. See his Atlas 
of Skin Diseases, Lief. III., Tafel 2. 



LICHEN RUBER. 259 

from the intermediate lesions above referred to. Itching is 
generally present in both varieties, and may be either slight or 
severe. 

Lichen planus commonly presents itself upon the extremities ; 
lichen acuminatus upon the trunk. Lichen planus is perhaps 
most often encountered about the forearms, and especially upon 
the flexor surfaces of the wrists. It is also often met with on the 
backs of the feet. It occurs also sometimes on. the palms and 
soles, and on the penis. It has, moreover, been met with upon 
the tongue, hard palate, and gums, as in the cases reported by 
Neumann and Pospelow.* It is generally more or less sym- 
metrical. As stated, it frequently appears in the form of rows, 
or of short or long, narrow or broad bands, and occasionally as 
though following nerve tracts. The course of the disease is slow, 
months sometimes elapsing without there being appreciable change 
in the lesions, while the process may continue for years. In other 
cases, however, in this country, the course is much more rapid. 
New lesions, as a rule, appear from time to time. As the papules 
disappear they are succeeded by violaceous, dark-red or brownish- 
red pigmentary stains, which, as a rule, are remarkably persistent. 
This pigmentation, even in the case of discrete lesions, is usually 
marked. The severe form, as described by Hebra, runs even a 
more chronic course, and is attended by a train of serious symp- 
toms, including constitutional disturbance, marasmus, and, at 
times, a fatal termination. Such cases, however, are very rarely 
encountered in this country. 

Etiology. — The causes are in many instances obscure. Wilson f 
is of the opinion that the disease is associated with symptoms of 
constitutional derangement connected with errors of digestion and 
nutrition, — a view which is also entertained by Taylor.J Patients, 
according to my experience, will generally be found to be suffering 
from debility arising from improper nourishment, overwork, ner- 
vous depression, and similar conditions. Nervous symptoms are 
often prominent. T. Colcott Fox § speaks in favor of its neurotic 
origin. Its occurrence in bands, as above stated, lends support to 

* Abstract in Lond. Med. Record, Feb. 15, 1881. 
f Diseases of the Skin, London, 1867, p. 192. 
X Arch, of Derm., vol. i. No. 1. 
\ Brit. Med. Jour., Aug. 23, 1879. 



260 INFLAMMATIONS. 

this view. The disease occurs at all periods of life, but is more 
frequent during middle age. It may also occur in children. Ac- 
cording to my experience, and that of Hutchinson,* it is more 
common in women than in men. Kaposi, on the other hand, has 
found it more common in men.f It is a comparatively rare dis- 
ease in this country. According to Wilson, it is not uncommon 
in England.^ 

Pathology. — The disease is to be regarded as an inflammatory 
process of a chronic nature, accompanied by considerable alteration 
in the structure of the skin. It is in all cases, and throughout, 
its course, a papular manifestation. Microscopical studies have 
for the most part been undertaken upon chronic cases. Accord- 
ing to Neumann § and Biesiadecki,|| the disease involves nearly 
all the layers of the skin as well as the sebaceous glands and 
hairs. The cells of the epidermis are accumulated in great quan- 
tity, and contain fine granular matter. The rete is highly de- 
veloped over and around the ©edematous papillae, which contain 
enlarged bloodvessels, along the course of which there exists an 
abundant proliferation of cells. Biesiadecki is of the opinion 
that each papule in its general structure consists of two parte, 
a central, atrophic portion, corresponding to the umbilication 
which is frequently observed clinically, and a peripheral, suc- 
culent, (Edematous portion, and that these features distinguish 
the papules under consideration from those of other diseases. In- 
teresting changes are also noted by both the observers quoted, 
and by Kaposi, in connection with the roots of the small hairs, 
which are seen to terminate abruptly in the form of tuft-like 
expansions. The root-sheaths are also found to be greatly hyper- 
trophied around the roots of the hairs, and to be distended by 
cell infiltrations to such an extent as to form knotty, club-shaped 



* Lectures on Clinical Surgery, London, 1879. 

t Path, und Ther. der Hautkrankheiten, p. 403. Wien, 1880. 

% See a valuable paper by Mr. Wilson, reporting a large number of cases, 
in the Journal of Cutaneous Medicine, vol. iii. No. 10, 1869. Mr. Wilson was 
the first to describe the disease in England, and gave to it the name Lichen 
Planus. 

I Loc. cit., p. 238. 

|| Untersuchungen aus dem Path.-Anat. Institute in Krakau, p. 32. Wien, 
1872. 



LICHEN RUBEE. 261 

extremities. The disease frequently has its starting-point about 
the follicles. 

According to the studies of Crocker,* the process is entirely 
superficial in the beginning, consisting of an inflammatory effu- 
sion from the superficial plexus of vessels. All the vessels of 
this plexus are notably dilated and the papillae enlarged by the 
growth of the interpapillary processes of the mucous layer down- 
wards. All of the epithelial layers undergo proliferation, those 
of the mucous layer taking the most prominent part in the forma- 
tion of the papule. The involvement of the hair-follicles, accord- 
ing to Crocker, is not an essential, nor even the main, feature of 
the process in most cases, the sweat ducts more often determining 
the position of the papule. 

Diagnosis. — Lichen ruber may be mistaken for the papular 
syphiloclerm, lichen scrofulosus, psoriasis, and eczema papillosum. 
In the- plane variety the irregular, angular outlines of the lesions, 
together with their flattened, slightly umbilicated, smooth or scaly 
summits, and dull red color, will, however, be points sufficiently 
distinctive to separate the disease from these affections. The 
papules of eczema papulosum, to which they bear the greatest 
resemblance, are roundish, somewhat acuminated, brighter red in 
color, usually intensely itchy, and possess a history different from 
that of the papules of lichen planus. 

Treatment. — A general tonic and supporting treatment is de- 
manded in the majority of cases. Arsenic is the most valuable 
remedy, and may be regarded almost in the light of a specific. 
The dose, at first small, should be increased from time to time, 
and the use of the remedy persisted in. Kobnerf recommends its 
employment in the form of hypodermic injections, using one part 
of Fowler's solution and two parts of water, beginning with four 
or five minims of the mixture. The preparations of iron, and cod- 
liver oil, are also useful. The sooner in the course of the disease 
treatment is instituted, the more speedy will be the cure ; cases of 
long standing are often found to be exceedingly obstinate, contin- 
uing for long periods but slightly influenced by remedies which 



* Lancet, vol. i., 1881. 

f Deutsche Med. Woch., Jan. 1, 1881. Abstract in New York Med. Jour, 
vol. i., 1881, p. 614. 



262 INFLAMMATIONS. 

in an earlier stage would have afforded relief. Hygienic measures, 
adapted to the requirements of the case, will be found to aid in 
bringing about a favorable result. Everything should be done 
to improve the general condition of the patient. 

Locally, inunctions with simple ointment, petroleum ointment, 
or tar ointment; alkaline lotions, and tar baths; carbolic acid and 
thymol lotions, varying in strength from half a drachm to two or 
three drachms to the pint; liquor picis alkalinus, diluted; corro- 
sive sublimate in the form of a lotion; and dilute hydrocyanic 
acid with water, may all be employed, ^'here the itching is a 
prominent symptom, I am in the habit of using a carbolic acid or 
thymol lotion with alcohol and a small quantity of glycerine, as 
in eczema, followed by a mild mercurial ointment. In addition 
to these, the various more stimulating remedies useful in eczema 
may be prescribed with the hope of success. 

Prognosis. — This will depend upon the severity of the case, the 
amount of surface involved, and the duration of the disease. 
Where the lesions are localized and not extensive, the prognosis is 
favorable. In the diffused form the disease is generally rebellious. 
In severe cases, according to Hebra, marasmus and a fatal termi- 
nation may take place. The disease is rarely so severe with us as 
in Germany. 

PRURIGO. 

Syn., Germ., Prurigo (Hebra i ; Juckblattern ; Fr.. Strophulus Prurigineux 
(Hardy) ; Serofulide Boutonneuse Benigne (Bazin). 

Prurigo is a chronic, inflammatory disease, characterized 

BY DISCRETE, ROUNDED, SMALL SPLIT-PEA SIZED, SOLID, FIRMLY 
SEATED, SLIGHTLY RAISED, PALE-RED PAPULES, ACCOMPANIED BY 
GENERAL THICKENING OF THE SKIN AND INTENSE ITCHING. 

Symptoms. — The disease commences by the gradual formation 
of small, firm elevations, which have their seat in the skin itself, 
appearing to be situated beneath the epidermis. At first they are 
often so slightly elevated as to escape being seen, but they may 
usually be felt by passing the finger over them. When fully de- 
veloped they are rounded, raised only to a very slight extent, and 
about the size of a millet seed or small split pea. They are firm 
in consistence, and may be detected by the finger as well-defined 
inflammatory deposits in the skin. They exist discretely, although 



phurigo. 263 

often in close proximity to one another. They are never grouped, 
but are more or less irregularly distributed. In color they are 
pale red or like that of the normal surrounding skin. They are 
frequently covered with a scanty, dry, shrivelled epidermis, but 
seldom to the extent of scales. They are often perforated by 
small hairs. 

The eruption is accompanied by intense itching, which symptom 
manifests itself early and remains present throughout the course 
of the disease. It is usually of so violent a nature that the patient 
is unable to desist from scratching, and consequently lacerates the 
lesions generally before they have completely formed. From re- 
peated and protracted scratching the summits of the papules become 
torn, and ooze a small quantity of bloody serum which dries into 
a crust. Hence, at all times blood crusts are present, and consti- 
tute marked secondary lesions. As the disease progresses, the 
itching and scratching increase to such an extent that excoriations 
result. In course of time a peculiar thickening of the skin takes 
place, attended by a harsh condition of the surface, which is char- 
acteristic of the disease, and in severe cases may be recognized by 
the touch. It is invariably most marked about the lower extrem- 
ities. The hairs here are seen to be either broken off short or to 
be torn from their follicles, the result of scratching. More or less 
pigmentation is also usually present. 

The disease has its seats of predilection, attacking by preference 
the extensor surfaces of the lower extremities, especially the region 
of the tibiae. The arms, particularly the forearms, are next in- 
vaded, and finally the trunk. The head is rarely if ever attacked ; 
the palms and soles never. In severe cases, owing to the great 
irritation and consequent scratching, the glands of the inguinal 
region become symmetrically enlarged and constitute " prurigo 
buboes," as Hebra has termed them. 

The disease almost invariably appears at an early age, — accord- 
ing to Kaposi, within the first or second year, — and in the form of 
an urticaria. It runs a chronic course, lasting usually throughout 
life. Eczema or simple dermatitis may at times be called forth 
by the inordinate scratching, as well as by the strong cutaneous 
irritants and caustics which are often used for the relief of the 
disease. 

Etiology. — The disease is extremely rare and almost unknown 



264 



INFLAMMATIONS. 



in the United States.* It is only occasionally encountered in 
France and England,! but is common in Austria, where it may be 
said to have its home. It is not hereditary, although it always 
shows itself at an early age, generally before the tenth year; nor 
is it contagious. According to Hebra, it is more often encoun- 
tered among males than among females. It is for the most part a 
disease of the poor. Its causes are to be found in impoverished 
conditions of the system, occasioned by bad food, improper hy- 
giene, and general neglect, Hebra justly remarks that "it un- 
doubtedly occurs almost exclusively in poor subjects and those 
ill nourished in childhood, and so most often in foundlings and 
beggars' children. Those who have enjoyed a good physical 
education in early youth, and have always been properly fed 
according to their age, suffer very rarely indeed from prurigo." 
Occasionally, however, it is met with in the upper classes. The 
disease is better in summer than in winter. After what has been 
said, it is scarcely necessary to state that it is never produced by 
pediculi or other parasites. 

Pathology.— The microscopic anatomy of the prurigo papule 
nas received study at the hands of Hebra, R. H. Derby,J Neu- 
mann^ Gay, and Kaposi. || The results, however, do not show 
that the process possesses distinctive anatomical features. The 
lesions differ but little from those of papular eczema. The views 
of Neumann and Gay are alike as to the origin of the disease: 
both these observers hold that the process begins in the papillary 



* Two cases occurring in this country will be found in the American Jour- 
nal of Syphilograpby and Dermatology, vol. iv. p. 21, 1873, recorded by 
Wigglesworth, of Boston, and in the Archives of Dermatology, vol. iv No 
2, 1877, by Campbell, of New York. 

f Among many thousand cases of skin disease which I had, some years 
ago, the opportunity of observing at the Hopital St. Louis, Paris, one case 
only of the prurigo of Hebra presented itself. It occurred in a lad about six- 
teen years of age, and was a marked example of the disease. Prof. Hardy, 
who was present, informed me that he designated the affection Strophulus 
Prurigineux. In London, among a large number of cutaneous diseases as 
met with at the various special hospitals and dispensaries, I do not recollect 
seeing a single case. 

J Sitzungsb. der Kais. Akad. d. Wissenschaft. Wien, Febr. Heft, 1869. 

I Archiv fur Derm, und Syph., Erstes Heft, 1871. Transl. in the Amer. 
Jour, of Derm, and Syph., vol. ii. p. 261. 

|| Loc. cit.. p. 445. 



PEURIGO. 265 

layer, the papule being formed by a circumscribed accumulation of 
young cells, with a certain amount of structureless fluid exudation. 
As the disease progresses, the epidermis and rete become highly 
developed and more or less pigmented. In chronic cases the 
whole papillary layer and the corium are hypertrophied and greatly 
thickened by the formation of a firm connective tissue ; the sweat 
glands and the vessels enlarged ; the outer root-sheath increased 
considerably in size, and the hair- follicles expanded in the form 
of a club. 

Diagnosis. — If the peculiar features of prurigo be borne in mind, 
no difficulty can arise in its diagnosis. It will be seen that a dis- 
tinct, clearly-defined disease has been described, which bears no 
relation whatever to either of the affections with which prurigo 
has long been confounded, — namely, pruritus and pediculosis. 
By reference to these latter diseases, their characters will be noted 
to be very different from those of prurigo. It will also be remem- 
bered that prurigo is an exceedingly rare affection in this country. 
Prurigo may be diagnosed from pruritus by the presence of the 
papules, which are primary ; in pruritus no papules exist, except 
those produced by scratching, which, of course, are secondary. 
Blood crusts exist in both prurigo and pruritus ; they are, how- 
ever, much more numerous in prurigo, and are seen to be seated 
about the summits of the torn and wounded papules. Prurigo is 
always attended with remarkable thickening of the skin, which is 
rarely the case in pruritus. The peculiar harshness of the skin 
in chronic prurigo is characteristic, and never occurs in pruritus. 
The regions attacked in prurigo are different from those usually 
invaded by pruritus; in the former disease the extremities, more 
especially their extensor surfaces, are involved, while in the latter 
the trunk or all parts of the body may be affected. The itching 
of prurigo is more intense and more constant than that of pruri- 
tus, and is relieved only by means which act upon the papillary 
layer of the skin itself, as, for example, violent scratching or 
caustics. Prurigo continues throughout life; pruritus runs a very 
variable course, and frequently disappears, with or without treat- 
ment. Prurigo is seen almost exclusively upon the poorly nour- 
ished and ill fed; pruritus is often encountered upon those who 
are in good general health, having its cause frequently in some 
functional derangement of the economy. 



266 INFLAMMATIONS. 

Prurigo should not be confounded with pediculosis. The two 
diseases have nothing in common. Pediculi are never present in 
prurigo; they are the sole cause of pediculosis, and consequently 
are always present. Small papules, due to scratched and inflamed 
follicles, covered with blood crusts, are at times seen in pediculosis ; 
but these are very different from the papules of prurigo, both in 
appearance and in course. The so-called papules of pediculosis 
are due to the wound of the pediculus, and the subsequent scratch- 
ing of the part. 

Prurigo may be confounded with eczema. As already stated, 
eczema may exist as a complication, especially when the prurigo 
is severe; in this event the disease will be found to remain after 
the eczema has disappeared. Examples of disease, however, are 
occasionally met with in this country partaking of the nature of 
both prurigo and eczema, the diagnosis in these cases being diffi- 
cult.* The two diseases, as a rule, however, are so different as 
not to permit of confusion. 

Treatment. — From a consideration of the cause of the disease, i( 
will be evident that immediate attention is to be directed to the 
general condition of the patient. The diet should be generous. 
Hygienic measures and everything that will tend to improve the 
state of the patient's health are to be taken into consideration. 
Iron, arsenic, quinine, and especially cod-liver oil may be pre- 
scribed. Great benefit is to be derived from external remedies, 
chief among which are to be mentioned the various kinds of baths. 
Tar and sulphur are the two most valuable remedies. Wilkin- 



* It will be observed that the author differs in his ideas of prurigo from the 
majority of English and American writers. The disease, as described, is a 
marked one, possessing a peculiar clinical history, and is entitled to be clearly 
separated from the other affections with which it has long been confounded. 
Prurigo, pruritus, and pediculosis are three very different diseases ; and yet 
one has but to turn to the literature of the day to find sad confusion. The 
difficulty has arisen from the fact that prurigo, as described by German 
writers, is an affection so rare in England and the United States as scarcely 
to exist in these countries, and is consequently unknown to observers. Both 
pruritus and pediculosis of the body, however, are often attended by the for- 
mation of hyperjemic elevations (especially about the follicles), followed by 
blood crusts from scratching, which lesions have erroneously been termed the 
papules of prurigo. In this manner, through complications, have the names 
of these three diseases been used interchangeably. 



LICHEN SCKOFULOSUS. 267 

son's ointment, as modified by Hebra,* may be used, and is highly 
spoken of by Hebra, Kaposi, and Neumann."]" 

Prognosis. — The disease is a very rebellious one, usually lasting 
years or a lifetime. It is said to be curable in the child, but 
scarcely so when it has lasted until adult life. 



LICHEN SCROFTTLOSUS. 

Lichen scrofulosus is a chronic, inflammatory disease, 
characterized by millet-seed sized, flat, reddish or yellowish, 
more or less grouped, desquamating papules, unaccompanied 
by itching, occurring in those of a scrofulous disposition. 

Symptoms, — The papules are always small; never larger than 
pin-heads. They are pale red, reddish, or yellowish in color ; at 
times, owing to the accumulation of minute scales upon their sum- 
mits, they present a grayish aspect. They show more or less dis- 
position to group, forming roundish or crescentic patches of various 
size in different parts of the body, which when they have existed 
for some time, are usually covered with minute whitish scales. 
The lesions when examined closely are found to have their seat 
about the hair-follicles. They are accompanied by little or no 
itching. The disease occurs chiefly on the trunk, more especially 
about the regions of the chest and abdomen, more rarely on the 
limbs. Its course is chronic, the individual lesions being slow to 
undergo involution ; it may last for years, old papules gradually 
disappearing and new ones taking their place. The skin is gen- 
erally dry, somewhat harsh, and of a yellowish hue.J 

Etiology. — The affection is certainly very rare in this country ; 
in my experience it is unknown. A case is reported by F. J. 
Shepherd, of Montreal. § It is most frequently encountered in 
Austria, where it was originally described by Hebra. Its cause 
is found in the scrofulous habit, nearly all in whom the disease 
is observed being affected with glandular enlargements, ulcers, or 

* See formula in the chapter on Scabies. 

f For detailed description of the various methods of treatment employed for 
this disease, see Hebra's interesting account as given in his work. 

J A representation of the affection under consideration may be found in 
Hebra's "Atlas der Hautkrankheiten," Lief. III., Tafel 3. 

| Canada Med. and Surg. Jour., Dec. 1880. 



268 INFLAMMATIONS. 

bone disease. According to Kaposi, this general cachexia is present 
in about ninety per centum of the cases.* It is encountered in 
young people, and more particularly at the age of puberty. In 
Hebra's experience it occurs much oftener in males than in females. 

Pathology. — The anatomy of the lesions, excised from the living 
subject, has been studied by Kaposi,f as follows. Each papule 
has its seat about the opening of a hair-follicle. The pathological 
process is an inflammation and cell-infiltration in and about the 
hair-follicles, sebaceous glands, and papillae around the apertures 
of the follicles. The inflammation, Kaposi holds, commences at 
first around the vessels and at the bases of the follicles and glands, 
and later invades the interior of these structures. The cells collect 
within the follicles and glands, to such an extent as to distend 
them greatly, thus forming the papules, and finally cause separa- 
tion of the hairs from their sheaths. The process may disappear 
without leaving cicatrices, or, on the other hand, it may be fol- 
lowed by pit-like, atrophic depressions at the seat of the follicles. 

Diagnosis. — The affection is not to be confounded with eczema 
papillosum, from which it materially differs in not itching. It is 
also to be distinguished from lichen ruber, from the small papular 
syphiloderm, and from keratosis pilaris, to which disease especially 
it bears likeness. 

Treatment. — The disease always yields to treatment. Cod-liver 
oil, taken internally and applied externally, is the remedy recom- 
mended, which, according to Hebra, never fails in relieving the 
condition. 

ACNE. 

Syn., Acne Vulgaris; Acne Disseminata; Varus; Stone-pock; Whelk; 
Genu., Finnen ; Fr. Acne ; Acne Boutonneuse 

ACNE IS AN INFLAMMATORY, USUALLY CHRONIC, DISEASE OF THE 
SEBACEOUS GLANDS, CHARACTERIZED BY PAPULES, TUBERCLES, OR 
PUSTULES, OR BY A COMBINATION OF THESE LESIONS, USUALLY IN 
VARIOUS STAGES OF DEVELOPMENT, OCCURRING FOR THE MOST PART 
ABOUT THE FACE. 

Symptoms. — Acne may appear alone, as a well-defined disease, 

* Loc. cit., p. 396. 

f Lekrbuch der Hautkrankheiten, Hebra und Kaposi. Erster Band, Zweite 
Auflage, 1874, p. 385. 



ACNE. 269 

or it may exist in connection with other affections of the sebaceous 
glands, as, for example, comedo and seborrhcea. It shows itself in 
the form of pin-head to pea-sized elevations, situated around the 
openings of the hair-follicles and sebaceous glands, which may be 
papular, tubercular, or pustular in their nature. Usually the dis- 
ease exists exhibiting both papules and pustules in all stages of 
development, from the incipient inflamed gland to the same in its 
suppurative stage. They are more or less acutely inflammatory, 
but are seldom accompanied by burning or itching. Exceptional 
cases, however, are occasionally encountered. In color they are 
bright or dark red or violaceous, with usually a central suppu- 
rating point. The number of lesions present varies extremely ; 
there may be only two, three, or half a dozen, or, as is usually the 
case, there may be a large number. The inflammation may be 
superficial, or it may extend deeply into the glands, occasioning 
considerable swelling and disturbance; sometimes abscesses are 
formed. The inflammation may, moreover, be acute or chronic, 
running its course either rapidly, in a few days' time, or slug- 
gishly, lasting weeks. The disease, taken as a whole, is almost 
always chronic in its course, crops of papules and pustules appear- 
ing from time to time, the process frequently continuing for years. 
According as the disorder has been more or less suppurative will 
cicatrices remain, which may be slight or disfiguring. 

Acne may occur upon any portion of the body except the palms 
and soles, but it has decided preference for certain regions. Its 
common seat is about the face ; it is also frequently seen upon the 
neck, shoulders, and back. It occurs upon all parts of the face, 
and in particular about the forehead, cheeks, and chin. In some 
cases the shoulders are attacked at the same time with the face. 
Occasionally it is encountered in a disseminate form over the. 
trunk, arms, and thighs, to the exclusion of the face. The erup- 
tion does not show itself with any regularity of distribution. It 
is, however, usually symmetrical. It varies greatly as regards 
development and general appearance, constituting either a slight 
disorder or a grievous disturbance attended by serious disfig- 
urement. It is one of the commonest diseases of the skin. It 
occurs chiefly in young people of both sexes, appearing ordinarily 
at the age of puberty. It rarely shows itself before this period 
of life, and seldom is present after mature years. Sometimes, 



270 INFLAMMATIONS. 

however, it first makes its appearance later in life. The varieties 
of acne may now be referred to, which are made according to the 
anatomical lesions usually observed. 

Acne Papulosa. — This consists in the formation of pin-head 
or pea sized more or less acuminated papules. They are usually 
small, sometimes miliary in size, partaking somewhat of the 
nature of comedones, with which they are often associated. The 
amount of inflammation is usually slight. A whitish or dark- 
ish point may frequently be seen in the centre of the papule, 
which has given rise to the term acne punctata, indicating the 
opening of the sebaceous gland duct. They generally exist in 
numbers, scattered over various parts of the face, their commonest 
seat being the forehead. Here and there will usually be found 
papulo-pustules, and even pustules, in various stages of evolu- 
tion. Acne papulosa is the least-developed variety of the disease. 

Acne Pdstulosa. — This is the typical variety. It may occur 
in all degrees of development, from pin-head to split-pea sized 
lesions. All acne tends to assume this form, but it rarely happens 
that the process is entirely pustular, intermediate lesions, as papules 
and papulo-pustules. usually assorting themselves. The amount 
of suppuration varies ; it may be slight or abundant. The pus- 
tules, as a rule, form rapidly, and terminate either in discharge of 
their contents by mechanical means or in absorption and desicca- 
tion. In shape they are rounded or acuminated, and are sur- 
rounded by a deep-seated or superficial inflammatory product. 
According to the amount of this peripheral inflammation will the 
pustule have an insignificant or a hard base; when it exists in a 
marked degree the condition is known as acne indurata, in 
which the subcutaneous connective tissue becomes involved, in 
some cases to such an extent as to occasion considerable swelling. 
This is frequently met with about the submaxillary region. The 
terms acne atpophica and acne hypertpophica have been 
applied to designate the results of acne in certain cases; the pro- 
cess in the first instance being followed by marked atrophy about 
the ducts of the glands, in the form of pit-like depressions, and 
in the latter by connective-tissue hypertrophy about the glands. 
Occasionally the sebaceous matter at the summit of the pustule 
becomes firm or even hard, in which case the disease is known as 
acne cornea. 



* ACNE. 271 

Acne Artificialis. — Under this head it is in place to speak 
of several kinds of acne which are produced by medicinal sub- 
stances, either taken internally or applied externally. In some 
persons tar used externally at times causes an inflammation of the 
sebaceous glands. It is observed especially upon those who work 
in tar. It is characterized by a blackish point, a deposit of tar, 
in the centre of the pustule. With the condition there exists 
more or less inflammation of the whole skin. The preparations 
of iodine and bromine taken internally are also frequently pro- 
ductive of glandular disorder. The eruption at times is of a 
serious nature, resulting in the complete involvement and destruc- 
tion of the sebaceous structures. The subject will be referred to 
more at length in connection with the subject of the medicinal 
eruptions. 

Etiology. — The causes which may give rise to acne are numer- 
ous, and are very different in their nature. The disorder may be 
occasioned by agencies operating directly upon the skin, or, as is 
much more frequently the case, by causes remote from the seat of 
the disease. Before mentioning these, it is in place to refer to cer- 
tain facts which observation has furnished. Acne is encountered 
in both sexes, in about the same proportion. It is more common 
in individuals who have light complexions than in those who have 
dark skins. The most frequent cause of acne is puberty. The 
affection first shows itself at this time of life, and is apt to con- 
tinue until the system has reassumed a condition of repose. It is 
at this period that the sebaceous glands everywhere are unusually 
active. The hairs also now begin to develop, and necessarily 
determine increased cell growth about the follicles. The whole 
sebaceous system undergo'es a great physiological change, which 
may occur quietly without occasioning disorder, or, as is frequently 
the case, may be of so violent a character as to give rise to any of 
the several functional diseases of the glands, and notably to acne. 

Among the causes which sometimes are observed to be pro- 
ductive of the affection, scrofulosis and general debility of the 
skin may be mentioned. Under this latter head may be grouped 
all those abnormal conditions arising from imperfect physical de- 
velopment, improper nutrition, and other defects of the econ- 
omy, whether organic or functional. The disease occurring from 
such causes is generally of the pustular variety, and is called 



272 INFLAMMATIONS. * 

CACHECTIC ACNE. In this connection anaemia and chlorosis may 
also be mentioned as causes, both of these conditions favoring 
the development of functional disease of the sebaceous system. 
Atony of the unstriped muscular fibres in the skin, which, as is 
well known, act directly on the sebaceous gland, must also be 
regarded as a cause of the disorder. 

One of the most common causes of acne is to be found in 
habitual derangement of the alimentary canal. Experience with 
a large number of cases teaches this in most emphatic language. 
Disorders of the stomach and bowels, including dyspepsia and 
constipation, are to be considered as among the most frequent and 
potent causes of the disease. In some cases, even slight derange- 
ment of the bowels is sufficient to bring forth the lesions, which 
will be observed to become better or worse as the internal condition 
is improved or neglected. 

Uterine disorders, particularly those of a functional character, 
are also to be viewed as the origin and direct cause of some cases 
of acne. Instances there are also, and it must be confessed they 
are not rare, in which it is extremely difficult, if not impossible, to 
find the source of the disease, the patient appearing to be otherwise 
in a perfect state of health. In addition to the causes enumerated, 
acne may result, as already stated, from the internal use of certain 
medicinal substances. Iodine and bromine are both frequently 
the cause of an acne-form eruption, which sometimes differs but 
slightly from ordinary acne. Among external agencies, tar like- 
wise at times causes an acne-form, inflammatory condition of the 
glands and follicles. 

Pathology. — Concerning the anatomical nature of acne there can 
be no question. The process originates and has its seat in the 
sebaceous glands and follicles of the skin. It is an inflammatory 
disease, involving the gland structure and the tissue surrounding 
it. The process for each individual papule or pustule is for the 
most part an acute one, running a definite course and terminating 
either in absorption or in suppuration. The first stage in the 
formation of the lesion consists in a retention of the secretion. 
This is soon followed by hyperemia and exudation about the 
gland and especially in its walls. The connective tissue about the 
gland now becomes infiltrated with cells and takes on more or less 
active inflammation, which sooner or later, as a rule, results in 



ACNE. 273 

suppuration. Cornil* finds the changes in simple acne pilaris to 
be distention of the follicular cavity with epidermic cells, and in 
the severer cases with a greater or less admixture of pus cells, 
small purulent collections in the rete mucosum, and congestion of 
the vessels surrounding the follicle. The intensity of the inflam- 
mation varies; if active, both the gland and the follicle may perish, 
leaving ultimately a cicatrix. The amount of inflammation present 
determines the two varieties of acne described, as well as at times 
certain other accompanying anatomical peculiarities, such as indu- 
ration and hypertrophy. 

Diagnosis. — The chief characters and the history of acne are so 
well defined in the majority of cases as to occasion no difficulty in 
diagnosis. The age of the patient, the locality attacked, the ana- 
tomical seat of the complaint, its chronic course, and the fact of 
the lesions appearing and disappearing within a short period, to- 
gether with their inflammatory nature, are points to be borne in 
mind in doubtful cases. Difficulty may sometimes arise in the 
recognition of artificial acne. That caused by tar may be known 
by the presence of this substance about the patient, which may be 
detected by its peculiar odor, and the blackish points at the open- 
ings of the follicles. The acne of iodine and bromine is highly 
inflammatory, is seen upon all parts of the body, and is generally 
extensive and virulent. The bromine acne especially is sometimes 
characterized by variously-sized areas of inflammation, which at 
times become covered with sebaceous crusts. 

Acne often bears a close resemblance to the papular and pustular 
syphiloderms, from which it must be distinguished by its history, 
by the absence of the various signs of general syphilis usually 
accompanying the syphilodermata, by its course, and by other 
peculiarities. Acne is usually scattered quite uniformly over 
the region attacked ; the lesions of syphilis tend to group. The 
disease occurring upon the forehead alone occasionally requires 
careful study to distinguish it from syphilis. Severe cases of acne 
may at times resemble variola in appearance, although error in 
diagnosis can scarcely occur. 

Treatment. — This may properly be considered under two heads, 
constitutional and local, both of which forms will be found of 



* Journal de l'Anatomie, etc., 1879. 
18 



274 INFLAMMATIONS. 

service. They should, in the majority of cases, be employed 
conjointly. With all the means at our command, the disease 
often proves rebellious. At the same time, the disorder is, in 
my opinion, by no means so obstinate as is commonly supposed. 

Constitutional Treatment. — Before entering upon active 
treatment it is necessary that the physician make himself thor- 
oughly familiar with the constitution and habits of his patient. 
It is impossible to treat acne satisfactorily without a clear under- 
standing of the causes which are at work in producing the dis- 
order. It must be remembered that it is a functional affection, 
and that therapeutics must be directed against the cause rather 
than against the individual papules or pustules, for these tend to 
disappear spontaneously. It should be the aim of the physician 
to prevent the disease from appearing. It is on this account that 
internal treatment is frequently found to be of much greater value 
in effectually disposing of the disease than external applications. 
If a case be watched in its course through a period of months, it 
will often be observed how closely the acne follows the general 
condition of the health. 

Various causes will be found to occasion the disease. It must, 
however, be borne in mind that the same cause, even if present, 
will not be productive of the disease in every individual. Disor- 
ders of one kind or another of the alimentary canal are in the first 
place to be inquired after. Dyspepsia, in its many forms, is one 
of the most prolific sources of acne; under this term are included 
irregularity of the bowels, constipation, flatulence, acidity, coated 
tongue, and other similar symptoms. Too much attention cannot 
be directed to the functions of the stomach and bowels, for de- 
rangement of these organs will be found to be at the bottom of 
many cases. To correct these difficulties is often extremely diffi- 
cult, requiring all possible skill, and it is in these cases that an 
accurate and thorough knowledge of general medicine, together 
with complete familiarity with the action of drugs, proves invalu- 
able to the physician. If constipation exist, saline or vegetable 
laxatives should be prescribed, in sufficient quantity to open the 
bowels once or twice in the day. An occasional dose of blue pill or 
of calomel will sometimes prove beneficial. In some cases aloes 
and iron may also be prescribed. AVhere there is a furred tongue, 
and disorder of the stomach as well as of the bowel, excellent 



ACNE. 275 

results may be obtained from an acid aperient mixture containing 
the following : 

R Magnesii Sulphatis, jfiss; 
Ferri Sulphatis, gr. xvi ; 
Acidi Sulphurici dil., f^ii ; 
Aquae Menth. Piperita?, f^viii. 
M. — Sig. Tablespoonful in a gobletful 
of water as directed. 

This preparation should be taken once a day, preferably a 
half-hour before breakfast. In some cases it may be prescribed 
twice daily, before breakfast and before tea. Where a vegetable 
bitter is desired, infusion of quassia or of col umbo or compound 
infusion of gentian may be employed in the place of water. The 
natural mineral waters are also valuable. The Saratoga waters, 
particularly the Hathorn and Geyser springs, as well as the Ger- 
man Friedrichshall, Ofner Rakoczy, and Hunvadi Janos waters, 
cathartics, Avill be found desirable and efficient, taken before meals. 
Together with these saline laxatives, it is often of advantage to 
direct some one of the ferruginous preparations. 

The preparations of sulphur, especially the sulphide of calcium, 
in from one-tenth of a grain to one-half of a grain, four or five 
times daily, as recommended by Ringer, will be found valuable. 
They sometimes succeed where other measures have failed. Cod- 
liver oil is sometimes called for, and is especially serviceable in the 
acne of young persons who are ill developed, spare, pale, and but 
half nourished. In these cases the affection is usually sluggish 
and non-inflammatory, and is, in fact, a mixture of acne and 
comedones. In women where there is menstrual difficulty the 
same general plan of treatment is to be pursued. The mineral 
acids are also of value in bringing up the general health. Arsenic, 
prescribed as a tonic, in two or three minim doses, is of decided 
service in certain forms of the disease. It may be ordered with 
benefit in the papular variety, and in those cases where the lesions 
are imperfectly developed. Minute doses of corrosive sublimate 
with bark will likewise sometimes prove useful in those cases 
where arsenic seems indicated. Gubler, of Paris, arid Bulkley, of 
New York, speak well of the use of glycerine in the punctate 
form of acne, administered internally, in tablespoonful doses, two 
or three times daily. It may be combined with citrate of iron 



276 INFLAMMATIONS. 

and quinine. Hygiene is of importance in many cases, especially 
where iron, cod-liver oil, and like remedies are indicated. Where 
it is not contra-indicated, a cold bath in the morning may prove 
of assistance in regulating the functions of the economy. The 
diet should always be directed. All kinds of heavy or indigesti- 
ble food, cheese, pastry, pickles, spices, and stimulating drinks, 
should be interdicted. 

Local Treatment. — The amount of inflammation, the pas- 
sive congestion so frequently present, and the retention of sebaceous 
matter, are all points to be taken into consideration in the treat- 
ment. There are two diverse, kinds of treatment which, according 
to the indications in the case, may be adopted. The one method 
calls for soothing preparations, the other for stimulating washes 
and ointments, with a view of arousing the glands to increased 
activity. In rare cases, where there is marked inflammation, ac- 
companied with heat and redness and a general hypersemia of the 
skin, mild washes and bland ointments will be found of service, 
the skin being treated as in any other simple inflammation. In 
the vast majority of cases, however, stimulating lotions and oint- 
ments are demanded, and may be at once prescribed. The face 
may be rubbed and washed every night or every other night with 
sapo viridis ami hot water, the application being made with a piece 
of flannel. One part of soap to equal parts of alcohol and rose- 
water may also be employed for the same purpose; or two parts 
of soap to one of alcohol, where a stronger preparation is needed. 
Equal parts of soap and glycerine, perfumed with oil of bitter 
almond, will also be found useful. Such applications serve to 
open the gland ducts and permit of a discharge or squeezing out 
of the contents of the glands. This may be done between the 
fingers or by means of a watch-key, as described in connection 
with the treatment of comedo. In pustular acne especially, hot- 
water cloths, applied at night, afford relief to the congested and 
swollen follicles, and render their ducts more open for the exit of 
the sebum. This may be followed in the morning by a cold douche 
and frictions. Among the more active remedies, sulphur and its 
preparations hold the foremost place. In my opinion they are by 
far the most efficacious remedies in the treatment of the disease. 
They may be ordered with benefit in a large number of cases, pre- 
scribed in the form of ointments or lotions. Sometimes excellent 



ACNE. 277 

result is obtained from using perfumed precipitated sulphur, pure 
or with starch, as a dusting powder, allowing it to remain on the 
face over night. The strength of sulphur preparations should be 
made to suit the case, varying from half a drachm to two drachms 
to the ounce. The following can be recommended as an eligible 

formula : 

R Sulphuris Praecipitati, ^i ; 
Glycerinae, fgss ; 
Adipis Benz., S|i • 
01. Bosae, gtt. iii. 
M. Ft. ungt. 

Sig. — To be thoroughly rubbed 
into the skin at night. 

Equal parts of sulphur ointment and petroleum ointment may 
be referred to as useful. Sulphur may also be employed to ad- 
vantage with alcohol, as in the following, suggested to me by Dr. 

Bulkley : 

B Sulphuris Loti, gi; 
.ZEtheris, f£iv ; 
Alcoholis, f ^iiiss. 
M. — Sig. Apply as a lotion. 
Shake the bottle before using. 

' The appended may also be employed as a lotion : 

$ Sulphuris Prascipitati, giii ; 

Glycerinae, fgii ; 

Alcoholis, f §i ; 

Aquas Calcis, f §ii; 

Aquse Bosae, f §i. 
M. — Sig. Shake the bottle before using. 

Another good formula, known as Kummerfeld's lotion, may be 

given : 

R Sulphuris Praecipitati, %iv ; 

Pulv. Camphorae, gr. x ; 

Pulv. Tragacanthae, ^i 

Aquae Calcis, fjfii; 

Aquas Bosae, f^ii. 
M. — Sig. Shake the bottle before using. 

Sulphuret of potassium likewise enjoys a reputation as a local 
remedy ; it may be prescribed as a lotion or as an ointment, in the 
strength of from five or ten grains to the ounce. The following 
formula may be given : 



278 INFLAMMATIONS. 

R Potass. Sulphured, £ii 

Tinct. Benzoini, f^iss ; 

Glycerinae, f^iii ; 

Aquae Rosae, fjviii. 
M. — Sig. Apply as a lotion. 

Sulphuret of potassium, one drachm ; sulphate of zinc, one 
drachm; rose-water, four ounces, will also be found a useful 
lotion, especially in the papular variety. Vlemiuckx's solution,* 
perfumed with oil of anise, diluted, one part to four of six of 
water, used as a lotion at night, may also be commended. When 
scaling begins, its use may be intermitted for a few days, or the 
lotion may be supplemented by some simple ointment to prevent 
this. In sluggish cases equal parts of sulphur, glycerine, carbon- 
ate of potassium, and alcohol, well rubbed into the skin every 
night or less frequently, may be prescribed with benefit; also an 
ointment consisting of equal parts of sulphur, glycerine, carbonate 
of potassium, and petroleum ointment or lard. 

Erasmus Wilson's well-known compound hypochloride of sul- 
phur ointment may also be mentioned, the formula for which is : 

R Sulph. Hypochloridi, ^iss ; 

Potass. Curli., gr. x ; 

Adipis Benz., 51 ; 

01. Amygd. Amar., m^v. 
M. Ft. ungt. 

The mercurials are also very valuable remedies. If sulphur has 
been previously used, the skin should in all cases be thoroughly 
cleansed before they are applied. The biniodide of mercury may 
be employed where active stimulation is required, in the strength 
of from five to fifteen grains to the ounce. 

The following formula of the late Mr. Startin, of London, con- 
taining sulphur and the red sulphuret of mercury, may be given : 

R Sulphuris Prsecipitati, gi ; 

Spts. Camphorae, n\xv ; 

Glycerinae, fjii ; 

Hydrargyri Sulph. Eub., gr. v ; 

Amyli, 5p ; 

Aquae, fgviii. 
M. — Sig. Shake the bottle before using. 
Apply as a lotion. 

* For formula see Psoriasis. 



ACNE. 279 

The corrosive chloride of mercury is likewise a well-known 
remedy. In my experience its action is uncertain. It is best 
prescribed as a lotion in the strength of from an eighth of a grain 
to one or two grains to the ounce. Emulsion of almonds con- 
stitutes an excellent vehicle for its employment, as follows : 

R Hydrargyri Chloridi Corrosivi, gr. ss ; 

Emuls. Amygdalae Amaras, f^iv ; 

Tinct. Benzoini, fgss. 
M. — Sig. Apply at night. 

The corrosive chloride of mercury constitutes the basis of the 
majority of the "lotions for the toilet" and cosmetics sold in the 
market.* Stimulating remedies are also found in the protiodide of 
mercury and in ammoniated mercury, both of which may some- 
times be used with good result where there is marked induration ; 
they may be prescribed in the form of an ointment, the former in 
the strength of from five to fifteen grains to the ounce, the latter 
double this strength. In severe cases of indurated acne, mercurial 
plaster may be applied, on cloths, during the uight, as suggested 
by Neumann. Medicated soaps, containing carbolic acid, thymol, 
sulphur, and glycerine, are often serviceable, and may be made use 
of with profit in conjunction with other remedies. The dermal 
curette, or scraper, has also been brought into service in the treat- 
ment of acne, and is especially useful in sluggish papular acne 
associated with comedones. The application of a minute quan- 
tity of the acid nitrate of mercury to the summits of the lesions 
is another mode of treatment, recommended by Hutchinson and 
other English dermatologists. The fluid should be applied cau- 
tiously with a pointed piece of stick or a fine glass rod, the pus- 
tules being lightly touched and the surplus acid at once absorbed 

* Absorption of mercury from the use of such preparations, producing 
symptoms of constitutional poisoning, while rare, nevertheless occasionally 
takes place. Cases have been reported by Eosenthal (Wien. Med. Presse, 
1876). Cosmetics containing lead are eminently dangerous, and maybe fol- 
lowed by serious diseases of the nervous system, and even by death. Such 
cases have been reported by Eosenthal (loc. cit.) ; Hutchinson (Phila. Med. 
Times, vol. iv. p. 241) ; Schenck (St. Louis Cour. of Med., May, 1879) ; Hol- 
land (New York Med. Kec, 1881, vol. i. p. 525) ; and Nagle (Physician and 
Surgeon, April, 1881). These face powders, often known as " flake white," 
commonly contain carbonate of lead. 



280 



INFLAMMATIONS. 



with blotting-paper. Scars are liable to follow, and for this reason 
I cannot regard the treatment with favor. Where the pustules 
are large and full, they should be opened by incision with the 
knife and their contents squeezed out. If there is distention of 
the superficial cutaneous bloodvessels, they should likewise be 
incised and permitted to discharge. The slight bleeding which 
follows the operation will prove beneficial. Rubbing the skin 
with fine sand, as recommended by Ellinger, is another mode of 
mechanical treatment of use in some cases, especially where comedo 
is present and where active stimulation is demanded. Sluggish 
papular lesions may sometimes be advantageously touched with 
carbolic acid, a minute drop being applied. The treatment of 
artificial acne simply requires the removal of (he cause, together 
with general directions as to local remedies, as may be demanded 
by the case.* 

Prognosis.— Experience teaches that cases of acne run exceed- 
ingly variable courses. The prognosis must depend in a great 
measure upon our being able to determine the cause and, at the 
same time, remove it. In many cases this is possible, and the 
result accordingly favorable. On the other hand, examples not 
infrequently occur where the cause is obscure or inaccessible, and 
the cases are generally stubborn. But the question as to result 
is one of time merely, for the disease sooner or later tends to 
spontaneous recovery, although without treatment it may continue 
for years, involving the skin in a destrtietive manner. In some 
instances it is a grave process, in that it is attended with extensive 
suppuration and obliteration of the glands and ducts, leaving cica- 
trices which are permanent and disfiguring. The scars may be 
either insignificant and superficial or so large and deep as to re- 
semble the marks of variola. Many cases of acne, on the other 
hand, leave no scars, suppuration and discharge or absorption 
taking place without destruction of the glands. The process 
may last a long while, often years if left to itself, and finally 
disappear as the cause has been gradually removed by changes 
in the general health and condition of the patient. 



* A study of " the treatment of the various forms of acne and of rosacea" 
will be found in a clinical lecture by 11. W. Taylor, Amer. Clin. Lectures, 
vol. iii., No. X., New York, 1878. 



ACNE ROSACEA. 281 



ACNE ROSACEA. 



Syn., Gutta Eosea; Gutta Rosacea-, Germ., Kupferrose ; Das Kupfrige 
Gesicht ; Fr., Couperose. 

Acne rosacea is a chronic, hyper^emic or inflammatory dis- 
ease OP THE FACE, MORE PARTICULARLY THE NOSE AND CHEEKS, 
CHARACTERIZED BY REDNESS, DILATATION, AND ENLARGEMENT OF 
THE BLOODVESSELS, HYPERTROPHY, AND MORE OR LESS ACNE. 

Symptoms. — There are three stages of the disease. It is char- 
acterized at first by a more or less diffuse hypersemia in the part, 
unattended by enlargement or swelling. This is of a passive 
character, the blood circulating slowly through the capillaries and 
inclining to stasis. If the nose be attacked, it is often greasy 
(seborrhoeic), and is apt to feel cold rather than warm. The 
process is usually a gradual one, months and years often being 
necessary for its development. In the course of time the second 
stage sets in. . The redness is noted to be more permanent in 
character, and subject to fewer changes. Upon close examination 
of the affected part, the minute ramifications of the cutaneous 
bloodvessels are seen to be dilated and enlarged, appearing as 
delicate or coarse, red lines running superficially over the skin. 
The course which they pursue is irregular; they run in all di- 
rections, and are for the most part tortuous. They vary from 
one to several lines in length. They also vary as to their calibre. 
Occurring upon the alse of the nose,. they usually run parallel 
with the cartilages of the alse ; over the nose they run for the most 
part irregularly. Sooner or later in the majority of cases acne 
papules and pustules manifest themselves. They appear here or 
there upon the part, and may be few or numerous ; as a rule, they 
occur in limited numbers. True acne rosacea is now developed, 
the disease consisting of rosacea — the dilated and hypertrophic 
bloodvessels — with papular or pustular acne superadded. It oc- 
curs in all degrees, from that which constitutes but a slight affec- 
tion to that which greatly disfigures the part. The face is the 
region attacked, and the nose is the usual seat ; occurring here, it 
may involve the alse, the tip, or the bridge. The cheeks are also 
often invaded, the disease either first appearing on these regions 
or spreading to them from the nose. The forehead is also some- 



282 INFLAMMATIONS. 

times attacked. I have seen it localized here in a most positive 
form, leaving the nose and the rest of the face free. Finally, all 
of the regions enumerated may be attacked simultaneously.* 

The course of the affection is usually a chronic one, lasting 
years. In some cases, however, it makes its appearance in a com- 
paratively short time, in the course of months; in. these instances 
there is simple dilatation of the vessels only, and no hypertrophy. 
The affection runs a variable course to its ultimate termination. 
The process is rarely, if ever, so violent in its nature in women 
as in men. Often it does not go beyond the first stage in women, 
hypertrophy being rare. Having, however, in either sex once at- 
tained certain degrees of development, it may remain in this state: 
or, on the other hand, it may continue increasing in its propor- 
tions, the process becoming more active year by year, until finally 
the cutaneous tissues are greatly hypertrophied, the bloodvessels 
enormously distended, the glands enlarged, and the part seriously 
altered. This condition constitutes the third stage of the process. 
These changes are usually observed in connection with the nose, 
which organ is not infrequently deformed. The new growth of 
connective tissue and bloodvessels at times goes on to such an 
extent as to give rise to a bulky formation. Noses of this kind, 
either with or without acne, may not infrequently be seen in the 
streets of large cities. They are red, usually of a dark-red or livid 
color, and are either simply enlarged, the normal proportions 
of the organ being preserved, or are contorted into various ir- 
regular shapes, more or less lobulated and pendulous. At times 
they assume monstrous proportions, and may be as large as a li-t 

(EHINOPHYMA.)t 

According as the disease is in one stage or another of its de- 
velopment, as well as at one time or another, will the part be cold, 
normal, or hot. In the first stage, that of passive hyperemia, 
especially in chlorotic women, the nose is often cold. Where the 
process is accompanied by the abundant formation of acne lesions, 
the part is apt to be warmer than normal. These symptoms come 



* See Plate E in my Atlas of Skin Diseases. 

■j- See a case reported by the author in the Photographic Eev. of Med and 
Surg., vol. ii., 1871-2. Also, Hebra's Atlas of Skin Diseases, Lief. VII., 
Tafel 6. 



ACNE ROSACEA. 283 

and go, and may be induced by excesses in eating or drinking, 
as well as by exposure to heat and cold. The disease is seldom 
attended with marked subjective symptoms. 

Etiology. — The causes are frequently of a diverse nature. The 
disease is met with in both sexes, but the causes may be different 
in the sexes. It is seen most highly developed in men. In 
women the complaint, in the majority of cases, does not pass be- 
yond the first stage, — that of hyperemia and stasis. It may, 
however, pass into the second stage, and is then characterized by 
permanent enlargement of the vessels. As Hebra first pointed 
"out, acne rosacea in women is noted to occur at two periods of 
life, namely, in early womanhood, and again later, at the climac- 
teric period, and is often attended by menstrual disorder. In the 
former of these periods the disease is not apt to be severe, and is 
usually observed to be associated with seborrhoea, and manifestly 
due to the same cause which has brought about this affection. 
With the disappearance of the seborrhoea the rosacea also gener- 
ally departs, either to remain away or to return later in life. The 
causes in these cases are to be found in chlorosis, menstrual diffi- 
culties of one kind or another, dyspepsia, and similar conditions 
of ill health. At the climacteric period, in both married and un- 
married women, the affection is liable to show itself in a severer 
form, attended with enlargement of the bloodvessels. 

In men, occurring early in life, in the first stage, I have not 
infrequently observed it to be associated with a seborrhoeic con- 
dition analogous to that seen in young women. Here, however, 
there is simply hypersemia, the bloodvessels being dilated but not 
permanently enlarged. Noses thus affected are often cold, not- 
withstanding their rosy hue. The causes in these instances are 
ansemia, general debility, nervous prostration, dyspeptic symp- 
toms, and other conditions which have been mentioned in speaking 
of seborrhoea. Spirituous liquors are known to be a frequent 
source of acne rosacea. Brandy, whiskey, wines, and other strong 
alcoholic drinks, taken in quantity and habitually, give rise to the 
affection in all of its stages, and upon various regions of the face. 
The " brandy nose" and the " wine nose," to be seen daily in any 
community, are common examples of the power that alcohol pos- 
sesses in producing the disease. On the other hand, there are 
cases, occurring in both men and women, in which no cause what- 



284 INFLAMMATIONS. 

ever for the development of the affection is to be found.* It is at 
times seen in those who are constantly exposed to the weather, as 
cabmen, etc.; but in these cases the condition is generally one of 
simple rosacea f rather than of acne rosacea. 

Pathology. — This has been already alluded to in describing the 
symptoms of the disease. .There are three grades or stages of 
acne rosacea, and according as one or another of these is examined 
will the changes be somewhat different, the difference between the 
first and the third stage being marked. In the first stage there is 
simply a collection of an undue amount of blood in the part, in 
the form of stasis. This condition may remain for an indefinite 
period — for months or years— without undergoing much altera- 
tion. Sooner or later, however, the second stage manifests itself 
by permanent dilatation and hypertrophy of the capillaries, to- 
gether with the involvement of the sebaceous glands, in the form 
of acne, either papular or pustular. The disease is now typical. It 
assumes a chronic action, is better and worse from time to time, 
and either remains in this condition permanently or goes on to the 
third stage. This is characterized by an exaggeration of the second 
stage, and is marked usually by more or less hypertrophy of all 
the tissues of the affected part, and a connective-tissue new growth. 
The nose at times becomes greatly distorted, and may assume 
various abnormal shapes. According to Hans Hebra's studies,! 
the enlargement is produced by an abnormal growth of connective 
tissue. The sebaceous glands are divided into lobules by new 
growths of connective tissue. In a case successfully operated on 
by Dr. C. Wagner,§ of New York, the microscopical examination 
by Dr. Piffard is given as follows. The horny layer was scanty, 
but the rete mucosum thick, with well-formed cells. The papilla? 
were enlarged in length and breadth, and contained round and 
fusiform cells. The sebaceous glands Mere not much altered ; 
some of the glands were normal, others were undergoing degen- 
erative changes. The corium was greatly thickened, and pre- 
sented the appearance of a formed tissue. 

*See a report of a clinical lecture on Acne Eosacea, by the author, in 
Med. and Surg. Reporter, Aug. 14, 1875. 
f See Eosacea. 

% Viertelj. f. Derm. u. Syph., Heft 4, 1881. 
I Arch, of Clin. Surg., vol. i. p. 21. 



ACNE KOSACEA. 285 

Diagnosis. — No difficulty should arise in recognizing the affec- 
tion when the history, course, and peculiar anatomical changes 
of the disease are borne in mind. It is a chronic disease. In 
this respect it differs from the tubercular syphiloderm, the disease 
with which it is most likely to be confounded. The course of the 
tubercular syphiloderm may be slow, at times continuing through 
a period of months ; acne rosacea, when pronounced, will in all 
probability have existed for years. In syphilis the tubercles or 
lesions do not specially involve the glands; in acne rosacea the 
seat of the pustules is always about these structures. Ulceration, in 
one form or another, may usually be detected about syphilis of the 
nose ; this process never takes place in acne rosacea. Crusts are 
apt to be present in syphilis; they never occur in acne rosacea. 
The tubercles of syphilis are generally much larger, firmer, and 
more pronounced than the lesions met with in acne rosacea. The 
color of syphilitic tubercles is a dull, coppery red ; in acne rosacea 
the color is usually either bright red or violaceous, according to 
the stage and form of the disease. In acne rosacea the superficial 
bloodvessels of the skin are enlarged and conspicuous, features 
that are wanting in syphilis. Acne rosacea usually attacks the 
end of the nose uniformly, both sides being involved ; syphilis is 
apt to localize itself, often more markedly on one side than on the 
other. The severer forms of acne rosacea, such as would be likely 
to be confounded with syphilis, are rarely encountered before the 
age of forty or fifty, and occur more particularly in men ; syph- 
ilitic disease of this character may show itself earlier in life. 
Finally, the history in doubtful cases will usually be of service 
in arriving at a conclusion. 

Lupus vulgaris may bear some resemblance to acne rosacea, for, 
as is well known, this disease is apt to make its appearance about 
the face, and especially the nose. In lupus vulgaris the- character- 
istic, roundish, yellowish or reddish papules and tubercles may 
generally be detected ; they are pin-head or larger in size, and 
usually involve only a portion of the nose, as the tip or one ala. 
Ulceration, moreover, followed by crusts and ugly cicatrices, takes 
place sooner or later in lupus, symptoms that are never present in 
acne rosacea. 

Lupus erythematosus can only be confounded with acne rosacea 
when it happens to show itself upon the end of the nose. The 



286 INFLAMMATIONS. 

skin in lupus erythematosus is harsh and covered with adherent, 
whitish or yellowish scales, which are connected with the openings 
of the sebaceous follicles ; in acne rosacea none of these symptoms 
are present. The first stage of acne rosacea, especially of the nose, 
may bear resemblance to frost-bite. The histories, however, and 
the symptoms will always serve to distinguish them. 

Acne rosacea may be known from acne by the presence of the 
enlarged bloodvessels and the hyperemia. The line dividing 
the early stage of acne rosacea from certain forms of acne is at 
times ill defined, for, as we have seen, the disease under consider- 
ation is made up of certain changes of the vascular system, together 
with acne. The involvement of the bloodvessels determines the 
case to be one of acne rosacea. 

Treatment. — The mode of treatment to be adopted will depend 
upon the stage of the disease, and upon the nature of the cause of 
the affection, where this is ascertainable. Both constitutional and 
local remedies are employed. The causes which have given rise 
to the process should be sought after. In women, uterine and 
menstrual disorders, and bowel derangement, are to be corrected 
by the appropriate remedies, and the general health in every way 
improved. In men, the use of all alcoholic drink is to be inter- 
dicted, and the bowels kept open by saline laxatives. The diet in 
both sexes* should be prescribed. The general treatment is that of 
acne, to which the reader is directed. 

Local treatment in the majority of cases is found to be of greater 
value than internal remedies. Stimulating preparations of one 
kind or another are suitable in all stages. In the first stage we 
may expect good results from the use of sulphur and the corrosive 
chloride of mercury. The former of these I have found by far 
the most valuable. It may be employed in the form of an oint- 
ment or as a lotion, as in the case of acne. From one to three 
drachms of precipitated sulphur to the ounce of ointment will 
generally be found serviceable. The English hypoehloride of 
sulphur may also be used in the same strength. Anderson gives 
the formula for a preparation composed of the hypoehloride of 
sulphur with rumex ointment,* two drachms to the ounce, which 



* The rumex ointment is prepared as follows : rumex root, nine ounces ; 
lard, six ounces; yellow wax, one ounce; water, sufficient quantity. "Wash 



ACNE KOSACEA. 287 

he speaks well of. Lotions containing sulphur, prepared accord- 
ing to the formulae given in speaking of acne, are often of great 
service, and in some cases more useful than ointments. Corrosive 
sublimate may sometimes be employed in the first stage with favor- 
able result, in the strength of from half a grain to two grains to 
the ounce, either of ointment or of alcohol; likewise the various 
officinal mercurial ointments. Mercurial plaster, spread upon 
cloths and applied to the part, may be employed in some cases 
with benefit, as recommended by Neumann and Hebra. 

In the second stage of the disease stronger applications are 
frequently required. The distended bloodvessels here should be 
incised with a sharp knife, and permitted to bleed. Cold-water 
cloths may afterwards be applied. This operation is to be re- 
peated once or twice weekly, according to circumstances. The 
part may, moreover, be scarified with parallel incisions, the opera- 
tion being repeated from time to time. Subsequently one of the 
sulphur ointments may be rubbed into the part. In the second 
stage I have also used caustic potassa solutions with good result, 
in the strength of from ten to twenty grains to the ounce, painted 
with a brush over the part once or twice weekly, followed by an 
emollient ointmeut. In cases where there is but little thickening, 
Neumann speaks well of brushing the part with a solution of one 
part of carbolic acid in three or four parts of alcohol, the appli- 
cation to be made every second day. Hardaway,* of St. Louis, 
recommends electrolysis for the obliteration of the enlarged ves- 
sels. The finest cambric needle, attached to the negative pole 
electrode of the galvanic battery, is used, the needle being inserted 
sufficiently deep to enter the dilated vessel. The circuit is then 
made by the patient taking the positive pole in the hand. After 
the electrolytic action has been properly developed, from six to 
ten elements of the battery being generally necessary, the patient 
releases the positive electrode, after which the needle is withdrawn. 
If the vessel is a long one, several punctures must be made per- 
pendicularly along its course ; if a short one, the needle may be 



and bruise the roots ; boil for two hours and strain ; evaporate to four ounces ; 
add gradually to the wax and lard previously melted, and keep stirring until 
cold. 

* Arch, of Derm., Oct. 1879. 



288 INFLAMMATIONS. 

inserted parallel with and into the lumen of the vessel. Fara- 
dization has been employed by Cheadle, who reports favorable 
results in several cases.* Piffardf also speaks well of both the 
faradic and the galvanic current. Where the process has been 
allowed to go on to the third stage, ablation of the diseased skin 
with the knife may be successfully practised, and is the only 
effectual remedy. 

Prognosis. — Where the process has not passed beyond the first 
stage, a favorable result may usually be looked for ; on the other 
hand, where a new growth of connective tissue has taken place 
about the vessels and around the glands, the prognosis should be 
guarded. Much, however, can be accomplished by judicious treat- 
ment, which in all cases will prove of more or less service. Left 
to itself, the disease exhibits no disposition to spontaneous cure, 
but, on the contrary, inclines to continue for years, altering the 
tissues of the part attacked in the manner already indicated. 

SYCOSIS NON-PARASITICA. 

Syn., Sycosis; Mentagra ; Acne Mentagra ; Folliculitis Barbae; Ge?'tn., 
Bartfinne; Fr., Sycosis Non-Parasitaire. 

Sycosis non-parasitica is a chronic, inflammatory, non-con- 
tagious DISEASE, INVOLVING THE HAIR-FOLLICLES, CHARACTERIZED 
BY PUSTULES, PAPULES AND TUBERCLES PERFORATED BY HAIRS, AC- 
COMPANIED USUALLY WITH BURNING SENSATIONS. 

Symptoms. — The disease commences by the formation of several 
or numerous papules or pustules surrounding the hairs situated 
usually about the region of the cheek, chin, or upper lip. New 
lesions, as a rule, develop, until a patch involving considerable 
surface results. They incline to appear from time to time in the 
form of successive crops. They have their seat immediately 
around the hairs. The pustules are either flat or acuminated; 
generally pin-head sized; contain a yellowish fluid, and show no 
disposition to rupture. They are discrete, and usually remain 
so throughout their course. Not infrequently, however, they are 
so numerous as to be crowded together. They are accompanied 
by marked redness of the surrounding skin, sometimes swelling, 

* Practitioner, July, 1874. 

f Mat. Med. and Ther. of the Skin. New York. 1881. 



SYCOSIS NON-PAEASITICA. 289 

and by sensations of a burning character and at times pain. If 
the beard be permitted to remain, they dry into crusts. In ad- 
dition to the typical pustules described, papules and papulo- 
pustules are usually present, and in some cases tubercles manifest 
themselves. More or less inflammatory thickening also generally 
exists, especially in cases of long duration. 

The cheeks, chin, and upper lip are the common seats of the 
disease • any one of these regions alone, or all of them at the same 
time, may be attacked.* The hairy portion of the neck may also 
be invaded. The affection may begin either by showing itself at 
once over all the parts, or, as is more usually the case, it may 
attack one portion and thence extend gradually to other regions. 
The hairs are usually so firmly seated in their follicles as to render 
their extraction more or less painful. The course of the disease 
is chronic. Without proper treatment it may continue for years. 

Etiology. — The causes are not well understood. The disease 
usually occurs between the ages of twenty-five and fifty. It is 
encountered among all classes of society, though in my experience 
by no means a common disease, and attacks the well-nourished as 
well as those surrounded by poverty. It is met with among those 
who do not shave, as well as among those who do; shaving, there- 
fore, cannot be regarded as its cause. It is not contagious. 

Pathology. — Non-parasitic sycosis is to be viewed as a simple 
peri-follicular inflammation. According to Robinson,f who has 
examined microscopically portions of living skin, the first changes 
which take place occur around the follicle, in the peri-follicular 
region, and are those which are usually encountered in vascular 
connective-tissue inflammations. The disease in its early stage, 
therefore, is not a folliculitis but a peri-folliculitis. As the inflam- 
mation proceeds, the follicle and its sheaths become affected, the 
latter becoming softened and more or less destroyed, and a portion 
of the surrounding pus may enter the follicle through the ruptured 
sheaths. At times no pus enters the follicle, the changes which 
take place being due to the serum which there collects. The 
cells of the root-sheaths and of the hair-root undergo destructive 



* A marked example of the disease invading all of the regions mentioned 
may be found in my Atlas of Skin Diseases, Plate H. 
f New York Med. Jour., Aug. and Sept. 1877. A valuable monograph. 
19 



290 INFLAMMATIONS. 

changes, the cell-bodies and connecting substance being first de- 
stroyed, a granular mass containing round bodies, the nuclei of 
the fixed cells of the part, remaining. The follicle-sheath and the 
connective tissue in the peri-follicular region are more or less 
destroyed, and the rete mucosum becomes ruptured on a level 
with the upper part of the neck of the follicle, the pus reaching 
the surface by forcing its way through the rete. According to 
Robinson, it does not pass between the shaft of the hair and the 
follicle-sheath as stated by Wertheini. 

The hairs in the early stages are always firmly seated in their 
follicles; later, through suppuration, they may become loose, but 
this does not always occur. The amount of suppuration varies in 
different subjects. The follicle-sheaths usually accompany the hair 
when extracted from pustules; upon this point Dr. Robinson's 
views differ, he stating that such is not the rule. The condition 
will be found to vary with the stage of the disease. The cavity 
remaining after extraction of a hair, where the follicle is not en- 
tirely destroyed, contains pus along its walls and at its base. The 
structures at the base of the follicle, including the papilla, may or 
may not be destroyed; where such destruction occurs, generally in 
the later stage, scars and permanent alopecia result. 

Diagnosis. — Non-parasitic sycosis is to be distinguished from 
tinea sycosis, from w T hich it differs not only in its cause, but also in 
its clinical features. These two diseases both attack the hair-follicle 
with inflammation, but produce such different symptoms as to call 
for a clear separation. The peculiar lumpy, tubercular, nodular, 
uneven surface of the skin, so characteristic of tinea sycosis, is gen- 
erally wanting in the disease under discussion. But the changes 
connected with the hair itself will be found of even more value 
than this symptom, and may be relied upon as a means of diag- 
nosis. In tinea sycosis they are loose, readily extracted from their 
follicles, and are seen to be twisted or broken, with a root that 
is often dry and manifestly diseased. Under the microscope the 
question of diagnosis offers no difficulty, for the presence or absence 
of fungus is easily demonstrable. Sycosis often bears a likeness to 
pustular eczema, from which, however, it may be known by the 
absence of oozing, as well as of itching ; eczema, moreover, attack- 
ing the beard, would be apt to be present upon other portions of 
the face. It will also be remembered that in sycosis each pustule 



SYCOSIS NON-PARASITICA. 291 

is penetrated through its centre by a hair. No difficulty will be 
experienced in distinguishing sycosis from the acuminated pustular 
syphiloderm ; the existence of pustules upon other regions of the 
face, as well as upon the body, would be sufficient to exclude 
sycosis. 

Treatment. — External treatment will generally be found of 
greater value than internal remedies. In obstinate cases, however, 
as well as in those which are associated with general impairment 
of nutrition, iron, small doses of arsenic, and cod-liver oil may 
often be given with advantage. Sometimes alkalies may be pre- 
scribed with benefit; in other cases saline aperients. The treatment, 
upon the whole, is similar to that employed in pustular eczema. 
Where there is considerable inflammatory thickening, Tilbury Fox 
speaks well of Donovan's solution. The general condition is to 
be looked after in all cases, as in other diseases of an inflamma- 
tory character. Exposure to all irritating influences should be 
avoided as much as possible, as, for example, the extremes of heat 
and cold. 

The first and most important step in the local treatment is to 
have the parts clipped or shaved. According to my experience, no 
rule can be given for either procedure; in some cases shaving will 
be tolerated and followed by relief, while in other cases clipping 
the hair close to the surface affords the best results. Shaving is to 
be performed every second or third day, according to the rapidity 
with which the beard grows. The hairs should at first be clipped 
with scissors, after which they may be macerated with poultice; 
when this has been accomplished, no great pain will be experienced 
upon shaving. After a few days the operation will be found much 
less painful, and in a short time, as a rule, may be performed with- 
out serious discomfort. Where the disease is acute and there is 
swelling, the inflammation is to be treated as in acute pustular 
eczema, by means of soothing lotions and ointments. The irrita- 
tion present should always receive due attention, and should be 
modified as much as possible. The applications to be employed 
must vary with the stage of the disease. If highly inflammatory, 
black wash may be applied several times through the day, followed 
by oxide of zinc ointment with a drachm of alcohol or ten or twenty 
grains of camphor to the ounce, spread upon cloths and bound to 
the part. A weak calomel ointment, fifteen to thirty grains to the 



292 INFLAMMATIONS. 

ounce of oxide of zinc ointment or petroleum ointment, may also 
be used, and will often be found a valuable remedy. Where the 
affection has existed for some time, the part may be treated by 
means of diachylon ointment and soft soap. The pustules are to 
be opened, and the skin well rubbed with soft soap and water, after 
which strips of muslin spread thick with diachylon ointment are 
to be applied and bound to the face. In other cases, a more stimu- 
lating plan of treatment may be used with advantage; for this 
purpose sulphur ointment, half a drachm or a drachm to the ounce, 
or ammoniated mercury, in the form of ointment, fifteen to thirty 
grains to the ounce, will be found of service. The ointment of the 
nitrate of mercury, one or two drachms to the ounce of ointment, 
may also be employed ; likewise the red oxide of mercury, from 
five to fifteen grains to the ounce. Corrosive chloride of mercury 
in the form of a lotion, from a quarter of a grain to a grain to the 
ounce of Avater or alcohol, may also be used in some cases with 
benefit. Sulphur lotions, as in acne, may likewise be prescribed 
with advantage. When there is much thickening of long standing, 
Dr. Robinson advises a weak preparation of the oleate of mercury 
with morphia, applied once every third or fourth day. Finally, 
as in the case of acne, the dermal curette may sometimes be used 
to advantage, as recommended by Auspitz,* and also by Behrend.f 
Depilation is recommended strongly by Hebra, Kaposi, and 
others, the hairs being extracted by means of a pair of depilating 
forceps. A small area is depilated each day, and the part after 
the operation dressed with diachylon or oxide of zinc ointment. 
The operation is generally more or less painful, and, according to 
my experience, can be tolerated only where there exists consider- 
able suppuration, and not always even in these cases. On this 
point, however, dermatologists differ, some stating that in the pus- 
tular stage the hairs are easily extracted. The part should be 
fomented with poultice or hot water before the operation is under- 
taken. Veiel, of Cannstatt, treats the disease according to the 
following heroic method. The hairs are cut short, the crusts re- 
moved with poultice, and a preparation consisting of two parts of 



* Ueber die Mechanisehe Behandlung der Hautkrankheiten : Viertelj. fur 
Derm. u. Syph., 1876. p. 586. 

f Deutsche Med. Wochenschr., No. 20, 1881. 



IMPETIGO. 293 

tar and one part of sapo viridis is rubbed into the skin, after which 
the hairs may be readily extracted. After depilation has been 
performed, acetic acid is applied with a brush. A crust is formed, 
which comes off in three or four days. The operation, if neces- 
sary, is to be repeated. Sulphur ointment completes the treatment, 
recovery usually taking place in four weeks. Where shaving has 
been practised, the patient should be directed to continue the opera- 
tion for months after the disease has disappeared. 

Prognosis. — The hope of a speedy cure should never be held 
out to the patient, for, while certain cases yield readily to treatment, 
others will be found to resist the most judicious remedies. 

IMPETIGO. 

Impetigo is an acute, inflammatory disease, characterized 
by one or more pea or finger-nail sized, discrete, rounded and 
elevated, firm pustules, unattended, as a rule, by itching. 

Symptoms. — The eruption may or may not be preceded by 
symptoms of general disturbance. When present, they are slight 
and consist of loss of appetite, constipation, or malaise. The dis- 
ease manifests itself by the formation of one or more distinct pus- 
tules. They begin as veritable pustules, the pustular character of 
the lesion showing itself in the earliest stage of the process. When 
fully formed, they vary in size from a split pea to a finger-nail. 
They are rounded in shape ; are raised prominently above the 
surrounding skin ; have thick walls ; and are at first surrounded 
with a more or less pronounced areola. The elevation is often 
striking, varying from an eighth to^a quarter of an inch, the 
lesions generally having a semiglobular form. There is no cen- 
tral depression or umbilication. The pustules are yellowish or 
whitish in color, and are usually tensely distended with fluid, and 
consequently are conspicuous. After they have arrived at matu- 
rity, the areola referred to generally subsides, leaving the lesions 
clearly defined. There is but little surrounding infiltration. 
Throughout their course they manifest no disposition to rupture. 
They are discrete, and occur here and there in a disseminated 
manner. Even when situated close together, as may occur upon 
the hands, they do not incline to coalesce. In number they vary 
from two or three to a dozen or more. They occur upon all parts 



294 INFLAMMATIONS. 

of the body, but are commonly seen about the face, hands, and 
fingers, feet and toes, and lower extremities; also upon the palms 
and soles. They are not attended, as a rule, by either itching or 
burning. The disease runs an acute course^ usually lasting sev- 
eral weeks. The pustules sometimes appear suddenly, and are apt 
to come out one after another during the first week of the attack. 
Having reached their full size, they remain in this condition for a 
day or two, when their contents become altered, at times bloody, 
and they undergo absorption or crusting. Frequently they are 
ruptured through contact with external agencies, when they pour 
out usually a thin puriform fluid; as a rule, it is not thick, as 
might be expected from the appearance of the pustules. If rup- 
tured or pricked with a needle early in their course, they may again 
fill with fluid. The amount of crusting varies : at times it takes 
place abundantly, yielding yellowish or brownish crusts; in other 
cases it is insignificant, the fluid undergoing absorption. Whatever 
crust remains desiccates and drops off, leaving a reddish base without 
pigmentation or scar. The disease is a benign process, inclining to 
terminate in speedy recovery. Relapses are not likely to occur.* 

Etiology. — It is an affection confined for the most part to chil- 
dren, and is usually encountered between the ages of three and 
ten. As a rule, it occurs in well-nourished and healthy subjects, 
who perhaps have had little or no previous illness. It does not 
appear to be in any way connected with eczema, nor is it usually 
associated with disorder of the stomach or of the bowels. In adults 
I have observed it chiefly upon the hands and fingers. It is not 
contagious. It is one of the rarer skin diseases. 

Pathology. — The lesion is a typical pustule. The first mani- 
festation upon the skin possesses all the characters of a true pus- 
tule, which continue throughout the entire course of the disease. 
The process is a circumscribed one. At no time during its course 
are the lesions seated upon a highly inflammatory base ; they rise 
abruptly from the surface much in the manner of the blebs of 
pemphigus. Anatomically the pustule is well formed, and pos- 
sesses thick walls, which are probably composed of both the horny 



* The disease I have described is, it seems to me, the only affection to which 
it is proper to apply the term Impetigo. The process is a distinct and well- 
marked one, and is worthy of the name. 



IMPETIGO. 295 

and the mucous layers of the epidermis. Microscopical examina- 
tions of the contents of the pustules, which I have made in various 
stages of the process, show the fluid to be of a whitish-yellow color, 
the color as well as the consistence of the fluid depending some- 
what upon the age of the lesion. Under two hundred and fifty 
diameters the field contains a variable number of pus corpuscles, 
more or less closely packed together, with here and there red blood 
corpuscles, epithelial cells, and cellular detritus. 

Diagnosis. — The disease has, I think, features sufficiently dis- 
tinctive to allow of its being separated from other affections to 
which it bears resemblance. It may be distinguished from pus- 
tular eczema by the size and peculiar conformation of the pustules. 
The pustules of impetigo are large and prominent ; those of eczema 
are small, and are not raised to the same extent. In impetigo the 
pustules are discrete, and do not incline to run together; in eczema 
they are usually seated close together, and manifest a disposition to 
coalesce. The pustules of impetigo rarely occur in numbers ; those 
of eczema are usually numerous. In impetigo there is but little 
infiltration; in eczema more or less thickening of the skin is a 
pathognomonic feature. In impetigo the pustules do not incline to 
rupture, and there is consequently no discharge; in eczema the 
pustules break early in their course, and are succeeded by exten- 
sive crusting; the exudation, moreover, is in these cases apt to 
continue. In impetigo there is little or no itching; in eczema 
the itching is generally marked. 

Impetigo bears a resemblance in its general features and course 
to impetigo contagiosa, which is to be viewed not as a variety of 
impetigo, but as a distinct disease. The initial lesion in impetigo 
contagiosa is a vesicle or vesico-pustule, similar to that of vaccinia ; 
in impetigo it is a perfect pustule. The lesion of impetigo con- 
tagiosa is superficial ; that of impetigo has a deeper seat. The 
pustule of impetigo contagiosa tends to flatten, and is often marked 
by umbilication ; that of impetigo is rounded, conspicuously raised, 
and without central depression. Impetigo, moreover, is not con- 
tagious. 

Impetigo also resembles ecthyma. In ecthyma the pustules are 
flat, and are surrounded by an extensive, inflammatory, hard base ; 
in impetigo they are elevated and rounded, and have generally but 
a slight areola. The crusts in these diseases are also different : in 



296 



INFLAMMATIONS. 



ecthyma they are brownish or blackish in color, are large and flat, 
and are seated upon a deep excoriation. Impetigo usually occurs 
in the strong and healthy; ecthyma in the weakly and cachectic. 
Treatment.— In the majority of cases but little interference is 
necessary. The pustules, as soon as they mature, may be opened 
with a sharp bistoury and the contents permitted to escape. The 
part should be protected from external influences, as rubbing of 
the clothes or other violence. The lesions may be dressed with 
some mildly stimulating ointment, as in the case of impetigo con- 
tagiosa. The affection inclines to spontaneous recovery. 

Impetigo Herpetiformis.— Under this name Hebra* has 
described a rare and grave form of skin disease of which at that 
time he had seen but five examples, four of which terminated 
fatally. According to Hebra, the disease is characterized by the 
formation of yellowish pustules, arranged in groups or in an an- 
nular form, which tend to run together and to dry into yellowish, 
greenish, or brownish crusts, beneath which there exists a red, 
moist, excoriated, non-ulcerating surface, similar to that of eczema 
rubrum. On the periphery of these patches new groups and rings 
of pustules manifest themselves. In all of the cases the patients 
were women, and were either pregnant or had recently been de- 
livered. The course of the disease was similar in each case. The 
anterior surface of the trunk and the flexor surfaces of the thighs 
were the chief seats of the lesions, but other regions, as the upper 
extremities, legs, neck, and back, and even the face, were invaded. 
Each outbreak of pustules was preceded by malaise, chills, fever, 
and general systemic disturbance.! Isolated cases, under differ- 
ent names, were before this date reported by Barensprung,J Neu- 
mann^ Auspitz,|| and Geber,^[ and were for the most part viewed 
as varieties of herpes. More recently C. Heitzmann has de- 
scribed a case, with the name impetigo herpetiformis, in a commu- 
nication presented to the American Dermatological Association.** 

* Atlas der Hautkrankheiten, Heft ix., Tafeln 9 und 10. Wien, 1876. 

t Wien. Med. Wocbensch., No. 48, 1872; also Lancet, March 23, .1872. 

t Atlas der Hautkrankheiten, Tafel 8. Berlin, 1867. 

I Lehrbuch der Hautkr., III. Aufl., Wien, 1873, p. 173. 

|| Archiv fur Derm, und Syph., II. Heft, 1869, p. 246. 

\ Jahresb. der K. K. Allg. Krankenhauses zu Wien, Jahrg. 1871. 

** Arch, of Derm., Jan. 1878. 



IMPETIGO CONTAGIOSA. 297 

Within the last ten or twelve years I have from time to time 
met with cases, occurring in both sexes, and representing other 
phases of the disease than heretofore described. In some cases 
the lesions were vesicular and bullous;* in others pustular; in 
still others, and in the majority of cases, bullous and pustular 
combined, or these lesions appearing alternately, — the disease 
being at one time vesicular and bullous, at another time pustular. 
In all instances the disposition to group or to extend about the 
periphery was more or less marked. A variable amount of con- 
stitutional disturbance, with violent itching, was always present. 
The disease manifested a disposition to constant recurrence, in the 
form of repeated attacks, extending in the majority of the cases 
over years, and was but little influenced by treatment. None of 
the cases occurred in pregnant women ; nor in any instance has 
the disease proved fatal. 

The disease is liable to be confounded with eczema, ecthyma, 
and pemphigus, according as the lesions existing at the time hap- 
pen to be vesicles, pustules, or blebs. The etiology and pathology 
of the disease are both obscure. In some cases it possesses many 
features in common with pemphigus, to which disease Heitzmann 
thinks it bears a close relationship^ other cases, however, manifest 
but little disposition to the formation of blebs.J 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is an acute, inflammatory, contagious 
disease, characterized by the formation of one or more super- 
ficial, discrete, roundish or ovalish vesico-pustules or blebs, 
the size of a split pea or finger-nail, which pass into crusts. 

Symptoms. — The eruption is usually preceded by slight febrile 
disturbance, especially in infants. Small, isolated, flat or raised 
vesicles are first noticed, which in a day or two become vesico- 

* In Hebra's fifth case the disease was characterized by vesicles and blebs, 
from which circumstance he was inclined to regard the disease as a variety of 
herpes, and designated it " herpes impetiginiformis.'" Lancet, March 23, 1872. 

f Arch, of Derm., Jan. 1878. 

X It is therefore evident that the process is capable of appearing in the form 
of varied lesions, and that the term impetigo herpetiformis represents but one 
variety of the disease. More information is needed before the disease can be 
assigned its proper place in classification. 



298 INFLAMMATIONS. 

pustules or pustules. At first they are small, but they tend to 
increase in size rapidly, until they may become as large as small 
blebs. They are roundish or ovalish in shape, and are at times 
marked by central umbilication. A slight areola usually sur- 
rounds them, -which, however, disappears upon their maturation. 
They rarely exist in numbers, as a rule, three or four or a dozen 
occurring at the same time. Not infrequently, when situated 
close together, they coalesce and form a small patch. In a few 
days, either from rupture or their natural course, crusts form ; 
these, indeed, are almost always present when the case first comes 
under observation. They are noticed to be flat, more or less ele- 
vated above the surrounding skin, yellowish or straw-colored, and 
but slightly adherent. Beneath them exist excoriations, which 
secrete a thin puriform fluid. After the crusts have become dry 
they fall off, leaving a reddish base, which gradually fades away. 
The lesions may all show themselves simultaneously, or they may 
appear in successive crops. The usual seat of the eruption is the 
face and hands; but the scalp and arms, as well as other regions 
of the body, may also be attacked.* The mucous membrane of 
the mouth and the conjunctiva? are sometimes invaded. It may 
be spread by auto-inoculation. Its course is usually a definite 
one, and lasts about ten days. It not infrequently happens that 
the disease assumes an anomalous or an abortive form, the lesions 
being either few, ill defined, or irregular in their course.f 

Etiology. — It is encountered chiefly among the poor and im- 
properly cared-for, although it is at times met with among those 
in the upper walks of life. Cleanliness exercises a certain control 
over the spread of the disease. It is confined almost exclusively 
to children. It is both contagious and auto-inoculable. The cause 
of the disease has not as yet been determined. In a number of 
instances it is known to follow vaccination 4 Sometimes it mani- 

* A typical, extensively developed case, in a boy aged 12, came under my 
care where the lesions occupied, and were confined to, the buttocks. There 
was no history of contagion. 

f Dr. F. P. Foster, under the name " herpes contagiosus varioliformis," 
has described a peculiar disease which resembles the affection under consider- 
ation. (Arch, of Derm., Jan. 1875.) Cases of impetigo contagiosa have been 
ably described by Dr. E. W. Taylor. See Amer. Jour, of Syph. and Derm., 
Oct. 1871, p. 368; also Bost. Med. and Surg. Jour., June 6, 1872. 

X The relationship between contagious impetigo and vaccination is as yet 



IMPETIGO CONTAGIOSA. 299 

fests itself in the form of an epidemic* It certainly is more 
prevalent some years than others. 

Pathology. — The views of observers are somewhat conflicting 
as to the nature of the disease, some holding that it is due to the 
presence of a vegetable organism, others that no such cause can be 
demonstrated. Kohn,f Piffard,| and Geber§ describe a fungus 
as existing in the crusts ; the growths discovered by the two first 
of these observers, however, are not the same. Kohn found a 
luxuriant parasite, consisting of thin, long mycelium, which w r as 
branched and fork-shaped, each thread terminating in a refractive, 
knob-like end. It made a thick net-work, here and there assuming 
the form of distinct loops. In general appearance it resembled the 
trichophyton as seen in tinea circinata, but dhTered from it in being 
not more than half as thick. Here and there it was observed to be 
in a state of fructification. The vegetable organism described by 
PifFard, on the other hand, is made up of variously shaped and 
sized, extremely minute, circular, oval, biscuit-shaped, and rod- 
like structures. Neither mycelium nor spores were present.|[ 
Geber looks upon the disease as a peculiar form of tinea circinata, 
and therefore as due to the trichophyton fungus, — a view which 
is, I believe, entertained by no one else. Radcliffe Crocker Tf has 
found micrococci, mostly in lines of fours, floating in the fluid 
derived from vesicles and pustules, which he suggests may be 
the source of the contagion. Other observers, myself among the 

not clear, but that some connection does at times exist seems probable. The 
cases which have come under my observation have on several occasions fol- 
lowed vaccination. 

, * See a paper by Dr. Arthur Van Harlingen, Med. and Surg. Eeporter, 
Sept. 8, 1877. Within a few weeks a large number of cases, from various 
districts of the city, came under observation at the several institutions with 
which Dr. Van Harlingen and the writer are connected. 

f Wien. Med. Presse, June 4, 1871. 

% New York Med. Jour., June, 1872. 

I Wien. Med. Presse, -Nos. 23 and 24, 1876. 

|| Dr. Piffard in his investigations twice encountered a fungus similar to 
that described by Kohn, but he inclines to the view of its being accidental. 

In the July number, 1872, of the New York Medical Journal, Dr. Piffard 
discusses impetigo contagiosa and its relations to vaccinia. A series of micro- 
scopic examinations upon the crusts of vaccinia were made, in all of which he 
discovered the same fungoid bodies found in impetigo contagiosa. 

\ Lancet, vol. i., 1881. 



300 INFLAMMATIONS. 

number, have not been able to demonstrate its parasitic nature. 
Tilbury Fox, to whom is due the credit of having first clearly 
described the disease,* has never been able to find the presence 
of fungus in the vesicles ; he, however, discovered such elements 
in the crusts, but he viewed their occurrence here as accidental. 

Diagnosis. — The affection is most liable to be confounded with 
eczema pustulosum and with impetigo; it may always be distin- 
guished from these diseases by the history, character, and course of 
the lesions. The crust is a superficial one, and often has the ap- 
pearance of being " stuck on." The lesions are usually isolated 
and itch but little, in both of which points they differ from those 
of eczema. The pustule of impetigo is prominently raised ; that 
of impetigo contagiosa is either flat or tends to become so. It 
may also bear a resemblance to varicella. Both affections usually 
show themselves about the face. The vesicles and vesico-pustules 
of varicella, however, are smaller, and are not attended with pro- 
portionately the same amount of crusting, nor are the crusts of 
the same character as regards their color and consistence. The 
usual distribution of varicella over various regions of the body 
will also serve to distinguish the diseases. The lesions of varicella 
are, furthermore, generally more numerous than those of impetigo 
contagiosa. Finally, the disease must be distinguished from pem- 
phigus, and from herpes iris. 

Treatment. — The mildest remedies are to be used, for the affec- 
tion tends to spontaneous recovery. Oxide of zinc ointment, 
together with cleanliness, will often prove sufficient. An ointment 
composed of ten grains of ammoniated mercury to the ounce may 
also be used advantageously. 

Prognosis. — This is always favorable. 

ECTHYMA. 

Ecthyma is characterized by the formation of one or more 
discrete, flat pustules, the size of a finger-nail, situated 
upon an inflammatory base, followed by a yellowish or 
brownish crust. 

Symptoms. — The pustules are usually well developed. They 
may exist either singly or in numbers, as many as a dozen being 

* Brit. Med. Jour., 1804; also in Jour, of Cutaneous Medicine, 1868. 



ECTHYMA. 301 

sometimes present. They are roundish or ovalish in form, cir- 
cumscribed, and generally exhibit a sharp outline. They are 
notably flat and broad, and consequently are seldom fully dis- 
tended. At first they are yellowish in color ; later, as a rule, they 
become somewhat reddish, owing to the admixture of blood. In 
size they vary from a small to a large finger-nail. Immediately 
around their margin the skin is generally of a bright-red color, 
forming an areola of considerable extent, which is usually firm 
and sensitive to the touch. After existing for a few days, the lesions 
become flaccid, begin to desiccate, and are converted into flat crusts 
of a brownish color. They are not adherent, and may be raised, 
when an excoriation, covered with a yellowish, sanious secretion, 
will be observed. The destruction of tissue scarcely amounts to 
ulceration. The extremities, especially the thighs and legs,* the 
shoulders, and the back, are the regions commonly attacked. The 
lesions have an acute course, developing and running their exist- 
ence in from ten to fifteen days ; after they have begun to crust, 
the process proceeds more slowly, and terminates in two or three 
weeks by the crusts falling off and leaving more or less pigmen- 
tation. The pustules are apt to appear successively during the 
first week or two. Where the cause is kept up, they may continue 
to show themselves for an indefinite period. The aifection is 
sometimes announced with slight febrile disturbance, which tends 
to subside upon the appearance of the eruption. Heat, more or 
less itching, and a certain amount of pain, accompany the lesions. 
Ecthyma is encountered upon both children and adults, and may 
occur at any time of life. It almost invariably manifests itself 
in those who are poorly nourished, overworked, and improperly 
cared for. 

Etiology. — The causes of the disease are to be found in all those 
influences which tend to lower the normal tone. It is most fre- 
quently met with in prisons, poor-houses, tenement-houses, and 
among those who live in squalor and poverty. It is rarely seen in 
the upper walks of life, except in children, who are usually deli- 
cate and poorly nourished. Improper and insufficient diet, want 
of ventilation, excessive work, and uncleanliness are all causes 
which may call forth the disease. In those predisposed to ecthyma, 

* See Plate J J in my Atlas of Skin Diseases. 



302 INFLAMMATIONS. 

acquired through an existence among the influences mentioned, it 
may be produced by various external agencies or irritants, among 
which the animal parasites and scratching occupy a conspicuous 
place. It is not contagious. It is, however, auto-inoculable, even 
through several generations of culture, as proved by the experi- 
ments of Vidal.* 

Pathology. — The affection is markedly inflammatory in charac- 
ter, and tends to the immediate formation of pus. The cutaneous 
disturbance is severe, as shown by the rapid development of the 
lesion, its size, and its firm, sensitively-inflamed base. It is a 
typical pustular process. Commencing as a pustule, it tends to 
assume speedily its definite proportions. The lesion is a super- 
ficial one, the excoriation not extending beyond the papillary 
layer of the corium. A slight scar is sometimes observed, which, 
however, is not permanent. Pigmentation also exists, which in a 
few weeks or months likewise passes away. In the colored race 
absence of the normal pigment is noted. 

Diagnosis. — Ecthyma may be confounded with eczema pustu- 
losum, impetigo, impetigo contagiosa, impetigo herpetiformis, and 
the large, flat-pustular syphiloderm. It may be known from 
eczema by the size and form of its pustules, as well as by the fact 
that they occur discretely. The inflammatory, firm base, with ex- 
tended areola ; the large, flat pustule ; its course ; the excoriation, 
and the yellowish, brownish, or blackish crust, will, moreover, 
serve to distinguish it from eczema. It may be known from im- 
petigo by the character of the pustule and crust. It differs from 
impetigo contagiosa in its non-contagious nature, the character 
of the lesion, the color and appearance of the crust, the region 
involved, and the general condition of the patient. It is liable 
to be confounded with impetigo herpetiformis, the lesions of which 
may sometimes closely resemble ecthyma; the history of the case, 
the course of the pustules, the grouping, and the manner of their 
spreading in the former disease will aid in the diagnosis. 

The disease bears a close resemblance to the large, flat-pustular 
syphiloderm.f Its course, however, is different from that of the 



* Annales de Derm, et de Syph., t. ix. No. 5. 

f I have found this to be particularly the case in the colored race, where 
the areola and color of the eruption are wanting. 



ECTHYMA. 303 

syphiloderm ; it develops itself more rapidly, and usually termi- 
nates in a few weeks. There is, moreover, more heat and pain, 
together with other signs of local disturbance, about ecthyma than 
about syphilis. The characters of the ulcers are sufficient to dis- 
tinguish the two diseases : in ecthyma the ulceration is slight and 
superficial ; in syphilis the edges are abrupt and more or less deep, 
and the excavation is covered with a thick, yellowish, puriform 
fluid. The crusts of ecthyma are brownish in color; in syphilis 
they generally have a duller or a dark-greenish tint. In ecthyma 
they are less bulky than in syphilis, and do not tend to heap up 
into layers. If the disease be syphilis, other symptoms will almost 
invariably be present, which will further aid in establishing the 
diagnosis. 

Treatment. — The affection yields readily to the proper remedies. 
All means should be adopted for the purpose of reinstating good 
health. The diet is of importance, and should consist of the most 
nutritious and wholesome food, including meat, eggs, milk, ale, 
and other articles calculated to improve the tone of the system. 
The hygienic surroundings should be inquired into; cleanliness, 
bathing, fresh air, exercise, proper rest, should all claim attention. 
It is to be remembered that the affection is one caused by debility. 
Tonics, such as the preparations of iron, arsenic, quinine, strychnia, 
and the mineral acids, will prove of value. The local treatment 
will vary with the stage in which the lesions exist. During the 
first week, alkaline baths, four to six ounces of the bicarbonate 
of sodium to the bath, may be ordered ; various cooling lotions 
may also be employed, as in eczema. Crusts are to be removed 
by poultice or water dressing, and a mild stimulating ointment as 
the following, applied : 

$ Ungt. Zinci Ox. Benz., gss; 

Vaselini, gss ; 

Hydrargyri Ammoniati, J)i. 
M. Ft. ungt. 

If the disposition to recovery be sluggish, the sores may be 
touched with more stimulating substances, as the nitrate of silver 
or dilute carbolic acid, or with a solution of chlorinated soda. 
The attention should be directed to the possible presence of para- 
sites and other external irritants. 



304 INFLAMMATIONS. 

Prognosis. — This is favorable. A few weeks usually suffice to 
restore the patient to health, provided a thorough change can be 
obtained and the treatment carried out. 



PSORIASIS. 

Syn., Lepra; Lepra Alphos ; Alphos ; Psora; Germ., Psoriasis ; Schup- 
penflechte; Fr., Psoriasis. 

Psoriasis is a chronic disease of the skin, characterized by 
reddish, dry, inflammatory, more or less thickened patches, 
variable as to size, shape, and number, covered with abundant 

WHITISH OR GRAYISH, MOTHER-OF-PEARL COLORED, IMBRICATED SCALES. 

Symptoms. — Psoriasis, like other inflammatory diseases of the 
skin, varies greatly as to the extent of its development, in one case 
showing a well-formed and typical eruption, in another imperfectly 
defined lesions. As a rule, however, it possesses characters which 
render it one of the most uniform and marked of all the cuta- 
neous diseases. It commences by the formation of small reddish 
spots, which immediately become covered with scanty or abundant 
whitish, imbricated scales. The lesions at this stage usually in- 
crease rapidly in size, and often in a few weeks or months develop 
into patches as large as coins. The scales are present from the 
beginning, and are seated superficially upon the reddened and in- 
flamed skin. The rapidity with which the first lesions sometimes 
extend is remarkable, especially when it is considered that the 
process soon settles into a chronic course. In other cases, how- 
ever, the eruption is sluggish from its commencement, spreading 
slowly, and perhaps involving only a small portion of the body. 
The amount of skin attacked varies exceedingly ; a great part or, 
in rare instances, even the whole surface may be the seat of disease. 
In other cases but a single small patch exists. As it is commonly 
encountered, it consists of numerous patches or islands of disease, 
scattered over the body, tending to run a slow but variable course. 
The patches, with perfectly healthy tissue between them, are quite 
characteristic, their generally sharp outlines causing them to stand 
out conspicuously. They may be either pale or bright red, or dark 
red, depending upon the amount of inflammation and locality, and 
are invariably covered with whitish or grayish, heaped-up scales, 
usually in such quantities as to mask more or less the color of the 



PSORIASIS. 305 

skin beneath. The margin of the patch in these cases is marked. 
When of any size, the patches are often slightly raised and may 
have a perceptible inflammatory border ; if the scales are plenty, 
the elevation is more manifest, in some cases rising to a consider- 
able height, after the manner of a limpet-shell. 

The scales are peculiar, and are characteristic of the affection. 
They are usually formed and cast off in great abundance ; the 
more active the inflammation the larger the quantity produced and 
discharged, so that, although at all times present, the amount varies. 
They possess a whitish, glistening mother-of-pearl color; and are 
imbricated and form laminse, which adhere but slightly to their 
bed. They may be readily scratched off, and when the skin is 
denuded a reddish surface may be seen, which on being scratched 
inclines to bleed in the form of minute pin-point drops. But 
there is never any watery discharge, the patch always remain- 
ing dry and scaly. Fissures may exist, especially when the 
disease attacks the joints or parts exposed to motion; they may 
likewise occur upon large patches. The degree of inflamma- 
tion attending the process varies. At times it is highly developed, 
as is manifested by intense redness, heat, swelling, and burn- 
ing or itching, while at other times, and usually, these signs 
will be less marked. More or less itching, however, not infre- 
quently attends the disease. Burning is also often a symptom 
when considerable surface is attacked with active inflammation. 
The affection is very rarely accompanied by any febrile disturb- 
ance. It is a conspicuously chronic disease, for, although indi- 
vidual patches may disappear, new ones generally show themselves, 
the disease in this way continuing for a long period. Even when 
all traces of it are lost for the time, relapses are the rule, which 
may occur at brief or at long intervals. 

The eruption assumes different features as to the size and shape 
of the patches, some of which are of such frequent occurrence as 
to be worthy of special names. These terms simply denote the 
form or outline which the disease has taken on, and do not apply 
to any difference in the character of the anatomical lesions. When 
the disease occurs as a small, pin-head sized eruption, it is known 
as psoriasis punctata. This is a rare form of the disease, for, 
though all cases begin in this manner, they seldom remain in this 
state, but, as a rule, quickly pass on to larger forms. Psoriasis 

19 



306 INFLAMMATIONS. 

guttata is the name given when the affection has assumed the 
form and size of drops, which, when covered with scales, look like 
drops of mortar. This is more commonly seen than punctata, 
though the process rarely stops at this stage for any length of time. 
Psoriasis nummularis, where the eruption resembles variously- 
sized coins, is the next stage encountered. The lesions not in- 
frequently cease to grow when they have arrived at this period, 
some being small, others large, and often remain in this condition 
throughout their career. At times the patches clear away in the 
centre, leaving the skin here normal, while they continue extend- 
ing upon their periphery, after the manner of tinea circinata; when 
this occurs, the condition is called psoriasis circinata. These 
circles are apt to coalesce sooner or later in the course of their exist- 
ence, forming broken semicircles and segments of circles, which 
may present a figured, festooned, or ribbon-like appearance, to 
which the name psoriasis GYRATA is given. When the patches 
are large, and irregular as to shape, covering a considerable amount 
of surface, the term psoriasis diffusa is employed to express the 
condition. As regards the size of the individual patches, they 
differ very much according to the severity of the process and other 
circumstances. At times they attain great size, and may be from 
three or four to eight inches in diameter ; where two or more 
patches have joined by their spreading into one another, extensive 
areas may exist, covering a considerable portion of a limb or the 
trunk. 

The disease may occur upon any part of the body, though it 
manifests itself upon certain regions in preference. The extensor 
surfaces of the limbs are particularly prone to the eruption.* The 
elbows and knees are frequently first attacked, and patches may 
exist here without the disease being present elsewhere. The back 
is more commonly involved than the chest. The face is more 
rarely attacked, but the scalp is often the seat of the disease. The 
palms and soles may also be invaded, either alone or in connection 
with the affection upon other parts of the body, but the disease 
here is rare. The nails at times suffer, but seldom, if ever, unless 
the eruption exists also upon the skin. The disease offers certain 
differences in appearance as it exists upon one part of the body or 

* See Plate B in my Atlas of Skin Diseases. 



PSORIASIS. 307 

another. Upon the scalp it frequently shows itself in the form 
of gyrate or irregular bands or streaks. Occurring here it is apt 
to extend itself somewhat upon the non-hairy parts ; thus, it is 
frequently seen about the ears, and upon the forehead near the 
line of the hair. When on the scalp alone, it is often difficult 
of diagnosis. Psoriasis probably never occurs upon the mucous 
membranes.* I have never seen it here. It is not contagious. 

Etiology. — The cause of the disease varies in different cases, 
there being no one known cause which occasions the eruption. 
On the contrary, it is seen to arise in conditions of the body which 
are diametrically opposite to each other, as in anaemia and pleth- 
ora. Unquestionably there exists in some individuals a predis- 
position to the affection, which may be inherited or be developed 
from some inappreciable cause. In these instances the disease 
tends to show itself at various times during the life of the patient. 

Psoriasis is usually encountered in those who have the best of 
general health, in those who are well nourished and stout, and also 
in those who have otherwise a fine, clear skin. On the other hand, 
it is also not infrequently seen in persons who are much broken 
down in health, and in the spare and poorly nourished. Sometimes 
it is noted to make its appearance during lactation and to disappear 
spontaneously after weaning the child. Cases in which the reverse 
is true are also encountered. It occurs in both sexes in about equal 
proportion. It may make its first appearance at any time of life 
after early childhood, but, as a rule, it rarely shows itself before 
puberty. Stel wagon f records a case where it appeared at the age 
of three. This is unusually early. It never occurs in infants. 
The common period for its manifestation is at about the age of 
twenty, but it may also first appear much later in life. It may be 
inherited, but according to my experience it is rarely so. The 
disease in the majority of cases encountered cannot be traced to 
either father or mother. It is never produced by syphilis, nor in 
any way connected with this disease, either directly or remotely. 
Syphilis gives rise to certain forms of eruption which closely 

* Cases of so-called psoriasis of the mouth, and especially of the tongue, are 
apparently not psoriasis, but other forms of disease. See papers by W. Fairlie 
Clarke, Practitioner, Aug. 1874, and Brit. Med. Jour., March 14 and 28, 
1874; also " Le Psoriasis Buccal," Paris, 1873, by Debove. 

f Phila. Med. Times, vol. xi. p. 458. 



308 INFLAMMATIONS. 

resemble psoriasis, but true psoriasis — a simple inflammatory dis- 
ease of the skin, attacking no other organ of the body — is an 
affection which must always be viewed as distinct from this disease. 

It occurs among the rich and the poor, and is to be found among 
all occupations without noteworthy difference, affecting those who 
indulge in exercise as well as those who lead sedentary lives. It 
is one of the commonest diseases of the skin, taking rank numeri- 
cally, in this country, after eczema and diseases of the sebaceous 
glands. The statistics of the American Dermatological Associa- 
tion furnish 533 cases out of 16,863 cases of skin disease.* Ac- 
cording to White's report of 5000 consecutive cases of skin disease 
encountered at the Massachusetts General Hospital, 152 cases of 
psoriasis were recorded. In Scotland the disease is commoner than 
in this country, Anderson reporting 725 eases among 10,000 cases 
of skin disease, f The seasons possess some influence upon it, but 
not so much as upon some other diseases, as, for instance, eczema; 
it is usually worse during the winter. Food and drink have little 
or no effect in the original production of the disease, though when 
once the process has taken possession of the skin it may sometimes 
be modified by diet. It is at times noted to be associated with 
gout and rheumatism, although the relationship is not of so close a 
nature as that which exists between these diseases and eczema.J 
Clinically, in rare cases, there exists some relationship between 
psoriasis and eczema, as shown by the observations of Neumann, 
Campbell, and others.§ 

Pathology. — The disease has a pronounced character, from which 
it seldom varies, rendering the pathological process one of the most 
definite which is encountered upon the skin. The degree to which 
the inflammatory symptoms may attain is variable, and dependent 

* Trans. Amer. Derm. Assoc, New York, 1879. 

f For additional statistics, see Dr. White's valuable article, "Variations 
in type and in prevalence of diseases of the skin in different countries of equal 
civilization." Trans. Internat. Med. Congress, Phila., 1877. 

J For further information upon this subject, see an able paper "On the 
Nature of the Gouty Vice," by Dr. Wm. H. Draper, of New York. Amer- 
ican Clinical Lectures, vol. i. No. XII., 1876. 

\ See Eczema, p. 181. Neumann and others also claim a traumatic origin 
for psoriasis; but the disease cannot be produced in this way unless there 
exists a disposition to its ready development. Viertelj. fiir Derm, und Syph., 
1 und 2 Heft, 1877, p. 262. 



PSORIASIS. 309 

upon the cause. The pathological anatomy has been studied by- 
several investigators. According to Hebra, who has had oppor- 
tunity of examining several cases of psoriasis after death, in 
patients who had died from intercurrent diseases, there remains 
but little to be seen upon the body. With the naked eye it is 
observed, that the redness of the patches lias left the surface, and 
that the scales are seated very superficially upon the skin. In 
opposition to the views formerly held, the disease is now regarded 
as an inflammation due to a hyperplasia of the mucous layer 
of the epidermis. Auspitz,* in an original and able article on 
the relation of the epidermis to the papillary layer, was one of 
the first to direct attention to the action of the cells of the rete 
Malpighii. Later, we find Tilbury Foxf enunciating views — 
founded on clinical observation and on the microscopic observa- 
tions of Neumann J — to the effect that the disease is not a true 
inflammation, but rather a " hypersemia with hyperplasia of the 
epidermis," consisting " primarily and essentially in a misbehavior 
of the cell elements themselves, — a perversion of the ordinary cell 
life of the epidermis." More recently Dr. A. R. Robinson, of New 
York, has investigated the subject very thoroughly and arrives at 
similar conclusions supported by the microscope. According to 
Robinson,§ the disease is essentially a hyperplasia of the normal 
constituents of the Malpighian layer. The increase takes place 
chiefly in the interpapillary portion of the layer, the growth of 
which downwards causes an apparent increase in the size of the 
papillae of the corium, which, however, on closer examination are 
found not to be enlarged. In the later stages of the disease the 
more superficial bloodvessels of the corium become dilated, a more 
or less considerable emigration of white blood-corpuscles takes 
place, and the immediate neighborhood of the vessels, together 
with the connective tissue of the corium, becomes the seat of a 
round-cell infiltration, which, with the effusion of serum, separates 



* Archiv fur Derm, und Syph. Erstes Heft, 1870. 

f Diseases of the Skin, 3d ed., p. 264. New York, 1873. 

% Neumann from his own studies interpreted the disease, on the other hand, 
to he an inflammatory process of the papillary layer and upper layers of the 
corium, accompanied by the excessive production of cells and enlargement of 
the papilla?. 

I New York Med. Jour., July, 1878. 



310 INFLAMMATIONS. 

the connective-tissue bundles and fibres into an open mesh-work. 
During the period of disappearance of the disease there is a gradual 
return to the normal condition until the hyperplasia, dilatation of 
the bloodvessels, and cell infiltration have completely disappeared. 
The hair in psoriasis is affected from the beginning of the disease, 
hyperplasia of the external root-sheath, the structure correspond- 
ing to the Malpighian layer of the epidermis, taking place, with 
extension of the hyperplastic structure into the surrounding cutis. 
The sebaceous and sweat glands are not at any time affected. 
Jamieson,* Tilbury Fox,f and Thin| have confirmed the correct- 
ness of Robinson's studies. 

Diagnosis. — The diagnosis of typical psoriasis does not present 
any difficulty, but there are cases frequently encountered where 
the lesions are very imperfectly developed, and where the appear- 
ance of the disease calls for more than casual examination. Ac- 
cording as the disease occurs upon one portion or another of the 
body, is it easy or more or less difficult of recognition ; thus, when 
upon the trunk it is usually characteristic, while upon the scalp the 
lesions are often ill defined. Ordinarily it exists as a diffused or 
scattered eruption, extensively present over the various regions 
of the body, and by taking into consideration the whole aspect 
of the disease the difficulty in diagnosis will be greatly lessened. 
Where there is doubt, the history of the case may be referred to, a 
point which will generally be of material assistance in forming an 
opinion. Psoriasis may be confounded with eczema squamosum, 
syphiloderma squamosum, tinea circinata, lupus erythematosus, 
seborrhcea, and pityriasis rubra. 

Eczema. — Occurring upon a limited portion of the body, it not 
infrequently bears a close resemblance to the squamous form of 
eczema. This is particularly the case when but one or two im- 
perfectly-defined patches exist upon the arms or legs. The appear- 
ance of the two eruptions in these instances is often strikingly 
similar, and the diseases may readily be confounded. The symp- 
tom of itching may or may not be present in psoriasis, and there- 
fore neither its absence nor its presence can be relied upon as a 



* Edin. Med. Jour., Jan. 1879. 

f Epitome of Skin Diseases. 2d Amer. ed., Phila., 1879. 

X Brit. Med. Jour., Sept. 4, 1880. 



PSORIASIS. 311 

means of diagnosis. In eczema, however, it is usually present to 
a much greater degree than in psoriasis. In the majority of cases 
of eczema there will be found also an account of the disease having 
been at some time in its course moist. Psoriasis, it is to be re- 
membered, is invariably a dry, scaly disease, never showing any 
sign of moisture. The. scales of psoriasis are much more abundant, 
larger, and whiter than those of eczema. The patches of psoriasis 
are usually well defined as to outline, while those of eczema gen- 
erally exhibit an indistinct border, fading away into the healthy 
skin. 

Syphilis. — Psoriasis and the papulo-squamous syphiloderm 
are frequently mistaken for each other, the diagnosis between 
them being at times extremely difficult. There are, however, 
points of difference which generally enable one to distinguish them. 
Psoriasis has a decided tendency to occur symmetrically ; when 
present upon one side, it is the rule to find it on the corresponding 
part. This observation does not apply to the syphiloderm, for it 
seldom disposes itself with any degree of symmetry, except in 
connection with the palms or soles, and even here it is subject to 
variation. Psoriasis inclines to involve a large portion of the 
surface at the same time ; the squamous syphiloderm rarely does. 
Psoriasis throws out an exuberant product in the shape of charac- 
teristic scales; in syphilis these are scanty. Psoriasis attacks 
remote parts of the body at the same time, as, for instance, the 
head and the lower limbs; syphilis confines itself, as a rule, to one 
region of the body. In psoriasis the elbows and knees are apt 
to be affected; in syphilis these regions are seldom involved. Oc- 
curring upon the palms or soles alone, the disease in the majority 
of cases will prove to be syphilis rather than psoriasis. 

The color of the patches in both affections is reddish, but it is 
likely to be of a brighter and more inflammatory tint in psori- 
asis, while in syphilis it is dull red or ham-colored. The scales in 
psoriasis mask the color of the skin and give the patch a whitish 
or mother-of-pearl hue ; in syphilis they are thin and scanty, and 
do not, as a rule, disguise the color of the skin. The infiltration 
in a patch of psoriasis is less marked than in syphilis, as deter- 
mined by taking a fold of the skin up between the fingers. A 
psoriatic patch shows infiltration with inflammation ; a syphilitic 
one, the deposit of a firm, new, cellular material. 



312 INFLAMMATIONS. 

The age of the patient may offer some clue to the diagnosis. In 
the majority of cases psoriasis will have manifested itself before the 
age of twenty ; this form of syphilis rarely appears before adult 
life. The courses of the two diseases are different. Psoriasis 
generally lasts for years, either continuously or in an intermittent 
manner; syphilis seldom remains in one form for any length of 
time. Other points of value in the history may often be brought 
out. Itching may, but seldom does, accompany this form of syph- 
ilis; it is not uncommon, and is sometimes marked, in psoriasis. 
In obscure cases the effect of treatment will generally decide as to 
the nature of the lesion. 

Tinea Circtnata. — Psoriasis at times resembles tinea circi- 
nata, but the patches of the latter disease are less inflammatory, 
red, and infiltrated. The scales in psoriasis are always more 
abundant than in tinea circinata ; they are, moreover, larger, more 
bulky, and winter. Tinea circinata shows no disposition to sym- 
metry in the arrangement of the patches, nor are the knees and 
elbows affected. The microscope establishes the presence of a 
fungus in the scales of tinea circinata ; no parasite is to be found 
in those of psoriasis. There is never any history of contagion in 
psoriasis ; there usually is in tinea circinata. 

Seborrhcea. — Seborrhoea not infrequently presents appear- 
ances similar to those of psoriasis, both on the scalp and on 
the body, about the back and chest. On the scalp the scales in 
seborrhoea are finer, smaller, and more disseminated than in 
psoriasis; they are, moreover, grayish or yellowish in color, 
greasy, and usually sebaceous in character. Psoriasis of the scalp 
occurs in distinct areas of disease; seborrhoea, as a rule, involves 
the whole surface. The patches of psoriasis are reddish and infil- 
trated ; the scalp in seborrhoea is pale or hypersemic, but is not 
infiltrated. Psoriasis rarely attacks the scalp without showing 
some signs at the same time upon the trunk or limbs; seborrhoea 
commonly has its seat upon the scalp alone. 

Lupus Erythematosus. — This disease can be mistaken for 
psoriasis only in its earliest stage. The involvement in the 
majority of cases of the sebaceous glands, as shown by their patu- 
lous ducts, will serve to distinguish it from psoriasis. Lupus 
erythematosus almost invariably attacks the face, being rarely 
seen upon other parts of the body ; psoriasis seldom appears upon 



PSOEIASIS. 313 

the face alone. Lupus erythematosus presents yellowish, seba- 
ceous scales ; psoriasis presents whitish, dry, imbricated scales. 
Lupus erythematosus is chronic in its course; psoriasis is liable 
to change its seat and character from time to time. 

Treatment. — This is to be considered under two heads, consti- 
tutional and local, both of which methods are of value. It is 
usual and proper to employ the two forms of treatment at the 
same time, for the disease is in the majority of cases most obstinate, 
demanding every available means for its relief. 

Constitutional Treatment. — Before undertaking to pre- 
scribe for a case, there are a number of points which should be 
ascertained. The disease should first be viewed in its totality, 
and a thorough study made of its history before any plan of at- 
tack is adopted. It will be found that different methods of thera- 
peutics are called for with the various cases that are met with, 
and that a course of medicine which would be of service to one 
case would be injurious to another. Attention should be directed 
to the general health of the patient : whether he be strong and 
fleshy or delicate and spare ; also whether there be any functional 
derangement which might act as an exciting cause of the attack. 
Regard must be given to the duration and course of the disease ; 
how long it has existed ; whether it has been upon the patient 
continuously, or whether it has tended to come and go from time 
to time or at stated intervals ; whether it is slight or extensive ; 
and, finally, whether it. is recent or of long standing. These and 
similar points are all of value in aiding us to institute a rational 
and satisfactory treatment. 

Among the medicines of most use in treating psoriasis, arsenic 
must first be mentioned. For the majority of cases arsenic, given 
judiciously, is the most efficacious medicine at our command. I 
say judiciously, because it is often prescribed in improper doses, 
and the patient allowed to continue its use indefinitely, causing 
frequently toxic effects, without affording relief. Like other 
potent drugs, it should be administered with due regard to the 
general condition of the patient's health, which should never be 
permitted to become deranged. The individual should be warned 
against its possible disagreeable effects, and should also be under 
the surveillance of the physician. The toxic symptoms should not 



314 INFLAMMATIONS. 

times positively injurious to the patient. Arsenic is by no means 
suitable for every case of psoriasis ; nor is it to be prescribed in 
every stage of the disease. If given in the acute stage it is liable 
to do more harm than good. It may be said, the less active the 
pathological process the more likely is it to be of benefit. If the 
affection, then, be attended with highly inflammatory symptoms, 
it is expedient to withhold its administration until this stage has 
relatively passed away. The less irritability, heat, itching, and 
infiltration about the patches, the greater the chance of the arsenic 
relieving the disease. It is an error to think that arsenic is useful 
in all stages of the disease. To procure good results, discretion 
must be exercised in its exhibition. 

In order to obtain the remedial effect of arsenic it is generally 
necessary to continue its employment for a considerable time, not 
infrequently for months, although improvement is usually observed 
in the course of weeks. It should be continued for some time 
after the symptoms have disappeared, the dose being gradually 
decreased. The most desirable form of administering it is the 
liquor potassii arsenitis, which admits of convenient mixing with 
other medicines, with which it may be prescribed. It may be 
given with wine of iron, or with a bitter infusion, as gentian or 
columbo, or with syrup of orange-peel or ginger and water. It 
should never be prescribed alone, or pure, the patient being di- 
rected to take so many drops for each dose. This mode has 
numerous disadvantages, chief among which are that an uncertain 
number of drops are liable to be takeu, through carelessness on 
the part of the patient, and also that when taken insufficiently 
diluted it is apt to disorder the stomach. It should be properly 
diluted with water and taken directly after meals. It is ordinarily 
convenient to order a four ouuee mixture, a fluidrachm being given 
for each dose, three times a day. 

A formula which I frequently prescribe is the following: 

R Liq. Potassii Arsenitis, f^iss ; 

Vini Ferri, f^iv. 
M. — Sig. One teaspoonful, with a wineglassful of 
water, three times daily, directly after meals. 

The dose here is three minims, an average dose. In an adult it 
is best to begin with not more than three minims, which quantity 



PSORIASIS. 315 

may from time to time be increased. Four, five, and even ten 
minims will often be tolerated ; but, taking a number of individ- 
uals, it will be found that the majority will not be able to take 
more than three or four minims for any length of time without 
derangement of the system. Arsenious acid, in pill form, may 
also be prescribed. The Asiatic Pills, as they are called, are em- 
ployed in various strengths, and have some reputation in the treat- 
ment of psoriasis ; but they are liable to produce gastric disorder, 
and are not' tolerated so well as Fowler's solution. Their com- 
position is as follows : 

R Acidi Arseniosi, gr. ii ; 

Piperis Nigri, Qii ; 

Pulv. Glycyrrhizae Kad., ^ii. 
M. Ft. in pil. no. xl. div. 
Sig. — One pill, three times daily, immediately 
after meals. 

The unpleasant symptoms arising from the use of arsenic should 
always be borne in mind, so that should they occur they may not 
be overlooked. They vary exceedingly. There are some persons 
who are extremely susceptible to its influence, and who are poisoned 
by it with the smallest dose. I have known half-minim doses to 
be sufficient to bring on alarming symptoms, such as redness, heat, 
dryness and irritability of the fauces, pain in the eyeballs, water- 
ing of the eyes, injection of the conjunctiva?, pains in the head, 
and derangement of the alimentary canal. Several of these symp- 
toms are usually present when the individual is under the toxic 
effect of the remedy, whether from a small dose, on account of 
an idiosyncrasy, or from a larger quantity saturating the system. 
Under such circumstances the medicine should be discontinued 
for a time, and a repetition of the accident guarded against. The 
disagreeable effects usually subside at once upon the suspension of 
the remedy. Arsenic is a safe medicine when given under the 
care of a physician ; but it should not be prescribed incautiously, 
any more than mercury or strychnine. 

Iron may be mentioned as being of some value in certain cases 
of the disease. It sometimes acts beneficially where there is lack 
of normal strength and tone. In women who have been nursing, 
in young persons of spare frame, and in those broken down in 
general health, it may prove of service. In the same class of 



316 INFLAMMATIONS. 

cases cod-liver oil may sometimes be ordered with good result, and 
a combination of this remedy with iron may be employed with 
advantage. But the cases must be selected if improvement is to 
be looked for. 

Phosphorus has been used with some success, although it cannot 
be regarded as a reliable remedy. It has been used by Hardy, 
Eames, and others, with varying results. According to my ex- 
perience, it usually produces gastric disturbance. The phosphide 
of zinc may also be used. Tar also may be prescribed with some 
hope of a cure ; Anderson speaks in favor of its efficacy in cases 
where arsenic and other remedies have failed. It should be given 
in the form of capsules, in from three to five minim doses, thrice 
daily. Carbolic acid is indicated in the same class of cases as 
the tar, and sometimes will be found efficacious. According to 
McCall Anderson, it is especially useful in chronic psoriasis where 
the patches are not much infiltrated. It may be given in from 
three to ten grain doses thrice daily. Anderson endorses it, and 
gives the following formula for its administration : 

R Acidi Carbolici, ^iii ; 

Glycerins, f§i ; 

Aquae Destillatse, f§v. 
M. — Sig. One teaspoonful, in a large 
wineglassful of water, before meals. 

The free use of alkalies sometimes proves of the greatest service. 
In patients who have a rheumatic or gouty tendency, or even 
where these conditions do not exist, liquor potassae may be pre- 
scribed with benefit in ten or twenty drop doses, largely diluted. 
I find it a valuable remedy. In these cases the salts of ammonium, 
potassium, and sodium are also serviceable. The carbonate of 
ammonium, in from ten to thirty grain doses, is favorably spoken 
of by Anderson. The acetate of potassium, in half-drachm doses, 
is also a remedy from which I have sometimes obtained good re- 
sults in highly inflammatory cases. The various natural alkaline 
springs may also be prescribed, as those of Vichy and Saratoga 
(Vichy Spouting Spring). Saline purgatives may occasionally be 
of value in promoting a better condition of the general health ; 
but they are to be employed only to correct manifest derangements. 

The diet in psoriasis is to be prescribed according to the require- 



PSOEIASIS. 317 

ments of the case in hand. As a rule, it matters little what psori- 
atic patients eat or drink, the disease not appearing in an)' way to 
be influenced by the amount or kind of food taken. Exclusive 
animal diet, taken for a period of weeks, is known to have been 
followed by the disappearance of the disease, as in the well-known 
case of Dr. Passavant, of Frankfort, Germany. Unfortunately, 
however, such a happy result is exceptional. In a severe case 
which seemed suitable for this mode of treatment I instituted a 
strict meat diet for three weeks, with no appreciable result; after- 
wards, a strict vegetable diet, at the end of which time the patient 
was about in the same condition as before treatment. 

Local, Tkeatment. — The use of external remedies must vary 
according to the duration of the disease, its extent, location, ob- 
stinacy, and the stage in which it exists. Regard, too, must be 
paid to the individual whom we have to treat, whether, for ex- 
ample, the patient be a man, a woman, or a young person, and 
whether it be practicable to carry out the plan that may seem 
most desirable. It is necessary to bear in mind that a course of 
treatment which could be successfully accomplished in the ward 
of a hospital would be impracticable in the rooms of the poorer 



The first point to be gained is the thorough removal of the 
scales. This may be done in one of several ways : by repeated 
washings with soft soap and water, by means of plain or alkaline 
baths, by detergent washes, or by caustic ointments. The bath 
is of especial service, accomplishing the object much more effec- 
tually and agreeably than any other method. When possible, 
it is always to be employed, for in no affection of the skin is 
it more beneficial than in this disease. The psoriatic patient of 
experience knows full well the comfort and benefit to be derived 
from its use. Preismann* recommends for removing the scales 
an alcoholic solution of salicylic acid, in the strength of one to 
sixteen. 

If the case be an acute one, with highly inflammatory symptoms, 
soothing applications, either of water or of bland oils or ointments, 
must be used, for the skin at this period will seldom tolerate the 
powerful stimulants which are in place in the later stage of the 

* Wien. Med. Presse, No. 16, 1879. 



318 INFLAMMATIONS. 

disease. Inunction with olive oil often proves serviceable in these 
cases, the patches being rubbed with the oil several times in the 
course of the twenty-four hours. Duckworth, of London, speaks 
well of the treatment, and I can also add my testimony to its effi- 
cacy. The majority of cases, however, when they present them- 
selves to the physician, are chronic, and are ready for stimulating 
applications. The patches having been deprived of their scales, 
one of the tarry preparations may be applied. These constitute our 
most useful remedies. Occasionally cases present themselves where 
they are not tolerated, even in the smallest quantity. Remembering 
this fact, it is proper never to apply any preparation of tar over a 
large surface until it has been ascertained that it agrees with the 
skin. Where there is an idiosyncrasy, or where tar is not suited 
to the case, the parts to which it has been applied immediately 
become red, swollen, hot, itchy, or painful. In the majority of 
cases, however, it is well borne and is of great service. 

Pix liquida, or common tar, oleum cadinum, or oil of cade, and 
oleum rusci, or oil of white birch, may be used. All of these prep- 
arations are efficacious, and may be compounded in various ways. 
An ointment composed of from one to two drachms of tar or of 
oil of cade to the ounce of lard, or of equal parts of oxide of zinc 
ointment and petroleum ointment, may be ordered. Wilkinson's 



R Sulphuris Sublimati, 

01. Cadini, aa^iv ; 

Saponis Viridis, 

Adipis, afi^i ; 

Cretae Pneparatse, ^ii^s. 
M. Ft. uns^t. 



Another preparation consists in a drachm or more of the oil of 
cade to the ounce of alcohol, likewise to be rubbed into the patches, 
with a piece of flannel or a stiff brush. In the application of any 
of the preparations it is of some moment that they should be used 
in small quantities and effectually worked into the skin. They 
should be firmly rubbed into the part, and not smeared upon the 
surface. This is an important point, and the physician should see 
that it is properly carried into execution. The cleansing of the 
patches and the application of the ointment or liquid should be 



PSORIASIS. 319 

attended to once or twice daily. The so-called tar bath may also 
be employed. It consists in freeing the patches of scales by means 
of potash soap, and applying tar or one of the derivative oils, and 
allowing the patient to remain in a warm bath for several hours. 
A mixture proposed by Hebra, composed of equal parts of pix 
liquida, alcohol, and sapo viridis, constitutes a preparation which 
is used with benefit in obstinate cases. Anderson has given it the 
name of "tinctura saponis viridis cum pice." Guyot's solution of 
tar, known as "goudron de Guyot," is a valuable preparation. 
It possesses the advantages of mixing with water in all propor- 
tions, does not emit such a pungent odor, and does not color the 
skin to the same extent. The " liquor picis alkalinus," referred 
to in considering the treatment of eczema, is a similar preparation, 
and may be used in the same manner as in eczema. The " liquor 
carbonis detergens," mentioned in eczema, is also useful. For 
most cases, however, ointments are to be preferred. 

Occasionally tar gives rise to symptoms of systemic disturbance, 
produced by its absorption. Of these, fever, headache, vomiting 
of dark-colored fluid, discoloration of the fasces and urine, may be 
mentioned. Upon its suspension, however, the symptoms subside, 
and are not followed by serious consequences. The greater the 
surface coated with tar, the more likely is absorption to take place. 
In the treatment of a case of psoriasis of ordinary severity it is 
rare to note any such effects. The long continuance of the use 
of tar is at times followed by an inflammation of the sebaceous 
glands. Creasote may also be used in the form of an ointment, 
varying in strength from a drachm to four drachms to the ounce. 
Squire speaks well of it in the strength of two ounces to one 
ounce of simple cerate. Turpentine will also sometimes prove 
serviceable. 

In cases where it is not practicable to apply the tar, on account 
either of the odor or of its disagreement with the skin, other oint- 
ments may be prescribed and used in a similar manner. Carbolic 
acid, as a lotion or ointment, will often prove valuable, though much 
inferior to tar. Crocker* regards thymol as a substitute for the 
tarry preparations, which possesses the advantage of being color- 
less and of having a not disagreeable odor. It may be used as 



* Brit. Med. Jour., Feb. 16, 1878. 



320 INFLAMMATIONS. 

an ointment in the strength of from five to thirty grains to the 
ounce. Where the patches are small and limited in number, good 
result may be obtained from the ointment of the nitrate of mer- 
cury, either in its officinal strength or weakened, — from one to 
four drachms to the ounce. The biniodide of mercury, from ten 
to thirty grains to the ounce, is likewise a useful remedy, much 
esteemed in France. The officinal white precipitate ointment, or 
an ointment of the protiodide of mercury, fifteen or twenty grains 
to the ounce, may also be mentioned as being serviceable. From 
five to fifteen grains each of the white and red precipitate to the 
ounce also constitutes a valuable ointment, much used in England. 
The oleate of mercury remains to be mentioned. It is of un- 
doubted value, and may be used in from five to twenty per cent, 
strength. Combined with tar ointment I find it very valuable in 
many cases, especially in psoriasis of the scalp. Lotions of cor- 
rosive sublimate may also be referred to as being sometimes of 
service. It is advisable, however, to limit the application of the 
mercurial ointments to comparatively small portions of surface, 
on account of the liability of absorption. In cases where the 
patches are the size of a coin, and obstinate, they may, as recom- 
mended by Anderson, be treated successfully with a cantharidal 
blistering fluid. The dermal curette has also been recommended 
in these cases, especially in conjunction with tar or other reme- 
dies. My experience with it, however, has not been satisfactory. 
Acetic acid will also sometimes prove serviceable. 

The treatment by chrysophanic acid, or ehrysarobin, as Lieber- 
mann determines the substance to be, introduced to the profession 
by Squire, may here be referred to. It is a golden-yellow crys- 
talline powder, soluble in alcohol, benzole, and hot fat, derived 
from "goa- powder" (a product of a Brazilian tree), which for a 
long time has had a reputation in Eastern countries as a para- 
siticide. It is best used in the form of an ointment, varying in 
strength from ten grains to one drachm to the ounce of lard or 
of petroleum ointment.* Squire and Kaposi give formulae for its 
preparation as strong as two drachms to the ounce ; but in these 



* As found in the market, it varies considerably in strength as it comes from 
one or another source. Caution should therefore be exercised in ordering the 
remedy, it being prudent to begin always with a weak ointment. 



PSOEIASIS. 321 

proportions it is to be handled with care. After a few applications 
the scales disappear, and the patches become whitish with a pur- 
plish, brownish discoloration about their edges and over the skin 
with which the ointment has come in contact. The remedy is a 
potent one and acts rapidly on the disease, destroying the lesions 
in some cases with remarkable celerity. Much has been said in 
praise of the treatment by many dermatologists since its introduc- 
tion a few years ago, while, on the other hand, others have been 
unwilling to accord the remedy such a high position. It has, as 
is well known, disadvantages, which, in my opinion, are serious 
arid tend to render its use limited. It is liable to irritate and 
inflame the skin, causing an acute dermatitis, characterized by a 
variable degree of swelling, heat, itching, and p«in, sometimes by 
follicular or furuncular inflammation, and always by a variegated 
purplish or mahogany-colored staining of the skin. The derma- 
titis not infrequently extends to the sound skin beyond the part to 
which the remedy was applied, and it may even appear in distant 
regions. Constitutional symptoms may also manifest themselves. 
The remedy should never be applied to the head, swelling and 
oedema of the eyelids being particularly liable to occur, nor over 
an extended surface. It contains a dye-stuff which, as stated, 
stains the skin badly, also the hair, the nails, and the linen of the 
patient. In all cases the preparation used should at first be weak, 
and applied to a small surface, until its strength and the sensibility 
of the skin have been ascertained. 

A similar, valuable, and less objectionable remedy exists in 
pyrogallic acid, which bears a chemical relation to chrysophanic 
acid, and was first used in the treatment of psoriasis by Jarisch. 
It is best employed as an ointment, in the strength of from ten to 
forty grains to the ounce. A drachm and a half to the ounce 
may sometimes be used, for example, on the scalp, but stronger 
preparations act. as caustics. It is painless, and causes no inflam- 
mation of the surrounding skin, but produces a brownish stain 
upon healthy as well as upon diseased skin. It also dyes the hair, 
light hair becoming brownish ; black hair is not much affected. 
Its action is slower than that of chrysophanic acid, but is effective. 
It should not be used over the whole surface, for the reason that 
constitutional symptoms, such as strangury and greenish or blackish 
urine, with fever, due to absorption, may occur. 
21 



322 INFLAMMATIONS. 

The benefits to be derived from the systematic use of sapo viridis 
in the treatment of psoriasis, as recommended by Hebra, demand 
a few words. This soap, which possesses caustic properties, may 
be rubbed into the patches without water and allowed to remain. 
The operation should be repeated twice a day for four or six days; 
then once a day, until about the tenth day; after which the patient 
is directed to apply nothing for five days, when a bath may be 
ordered. The bath should not be taken until the epidermis has 
begun to loosen itself; if water be applied while the soap is still 
being used, or before the exfoliation has occurred, tension and a 
disagreeable sense of shrinkage of the skin, with Assuring, will 
happen. 

The soap, with water, or with alcohol, in the form of the 
"spiritus saponatus kalinus" of Hebra, composed of two parts of 
soap and one of alcohol, may be employed with excellent result in 
psoriasis of the scalp. This may be followed by the " tinctura 
saponis viridis cum pice" or by a mixture of oil of cade and oil 
of sweet almond, a drachm to the ounce. Carbolic acid, ten or 
twenty grains to the ounce of alcohol or glycerine and water, is 
also useful. In obstinate patches of psoriasis, of limited size, a 
solution of sulphuret of calcium may be employed with excellent 
result, as in the following formula : 

R Calcis, *ss; 

Sulphuris Sublimati, 3i ; 

Aqufe, £x. 

Coque ad S;vi. deinde filtra. 
Sig. — " Vleminckx's Solution." 

This may be perfumed with oil of anise, five or ten drops to 
the ounce. It should be rubbed into the part with a piece of 
flannel, until slight bleeding takes place. The patches should 
then be bathed with cold water and afterwards anointed with a 
bland oil or cerate. The treatment is generally effectual, but is 
sometimes painful; it should not be used where the disease is 
extensive. 

Mention has been made of the bath only as a means of getting 
rid of the scales ; it is also to be considered as a curative remedy. 
Various mineral baths are at times of benefit in relieving the dis- 
ease, if not effectually at least temporarily ; they should be em- 



PITYRIASIS RUBRA. 323 

ployed continuously for several hours daily. Those containing 
sulphur are to be especially recommended. 

In cases where the eruption is localized, good service may be 
obtained from cold-water packing. The part — as, for example, a 
limb — is to be wrapped with a cloth wrung out of cold water, and 
this enveloped in oilskin, paraffine paper, or some other imperme- 
able dressing. It may be done at night and allowed to remain on 
till morning. More extensive methods of cold packing may also 
be employed with advantage, the whole body being treated in the 
same manner with wet sheets, and surrounded by blankets in the 
place of oilskin. The patient should be enveloped and tied up 
with the sheet, and well wrapped up in a blanket. After remain- 
ing in this condition for an hour or two, a cold plunge bath may 
be taken, to be followed by a walk or exercise of some kind. 
Abundance of drink should be permitted the patient, thereby 
promoting perspiration. The process may be repeated once or 
twice in the twenty-four hours. 

Prognosis. — As a rule, psoriasis tends to frequent relapses. An 
attack may last a few months, and under appropriate treatment be 
made to disappear completely. After an interval of an indefinite 
period, it will, however, usually again show itself. In severe cases 
relapses may occur continually, the patient rarely being entirely 
free of the disease. On the other hand, psoriasis of a mild type — 
of which instances are not infrequent — must receive a more favor- 
able prognosis. Each case encountered, however, will be found to 
possess certain peculiarities, which must be consulted as regards 
treatment. Psoriasis left to itself runs a variable course, which it 
is impossible to predict, inasmuch as its manifestations are often 
capricious. It is one of the most stubborn of the inflammatory 
diseases of the skin, and, as a rule, is rebellious. 

PITYRIASIS RUBRA. 

Pityriasis rubra is an inflammatory disease, involving 
usually the whole surface, characterized by red coloration, 
and abundant and continuous exfoliation of epidermis in the 
form of large, thin, whitish scales. 

Symptoms. — The affection usually begins in the form of small, 
red, scaly patches upon one or various regions of the body. These 



324 INFLAMMATIONS. 

increase in size and coalesce, forming larger patches, which may 
in a short time invade the greater portion or the entire surface. 
The disease usually makes its appearance rapidly. The surface 
is uniformly reddened and covered with whitish or grayish scales, 
which are being continually cast off and reformed. The color 
may be a pale, vivid, or violaceous red. The scales are, as a 
rule, extremely abundant, and are composed of thin, dry, papery, 
exfoliated epidermis. They are large, varying in size from two 
or three lines to an inch or more in diameter. They are some- 
times more appropriately termed flakes, and may resemble in 
outline the tiles of a roof, one overlapping the other. They are 
loose ; free at one or more edges ; more or less curled up ; and 
may usually be picked oif without causing pain. When the skin 
is deprived of the scales it possesses a somewhat shining aspect. 
When the disease is marked, the desquamation is rapid and abun- 
dant, large amounts of epidermis being shed in the course of the 
twenty-four hours. During the night, one, two, or more handfu!s 
may be formed, loosened, and accumulated in the bed. 

The skin, as a rule, is not at all thickened ; it may usually be 
pinched up between the fingers, and in this respect differs from 
the skin in psoriasis and eczema. Sometimes, however, in chronic 
cases there is here and there considerable thickening. But the 
amount of infiltration will vary, and the presence of this symp- 
tom should not exclude the disease.* The process is always dry. 
It is usually superficial in character, only the upper layers of the 
skin in most cases being involved. At times there is oedema, 
especially of the limbs; stiffness of the joints may also be present. 
Fissures seldom occur. The nails may or may not be affected ; 
in severe cases they may be softened and in a state of exfoli- 
ation. The whole surface is usually affected, no region remaining 
exempt. The palms and soles sometimes escape. 

Usually there are no marked itching or burning sensations. The 
patient complains rather of the disagreeable condition of the skin 
than of decided subjective symptoms. Occasionally, however, in 
grave cases, these symptoms may be present, coming and going 



* See an instructive case, which was under my observation in the Univer- 
sity Hospital for six months, where there was considerable thickening of the 
skin, Phila. Med. Times, Jan. 17, 1880. 



PITYRIASIS RUBRA. 325 

from time to time. It has been noted in most cases that patients 
readily feel the cold or suffer from a more or less constant feeling 
of chilliness. Constitutional symptoms may or may not be pres- 
ent; as a rule, they are slight or altogether absent. In some cases, 
however, they have been recorded as being severe, consisting of 
repeated febrile attacks, marked elevation of temperature, and 
signs of general disturbance. The disease may be either acute or 
chronic, more often the latter; it may continue months or years. 
Relapses are not uncommon. The affection may last for years, 
recurring in attacks, as in Dr. McGhie's case, which was under 
observation through a period of seventeen years, during which 
time many relapses took place. It is a disease of adult life, 
occurring usually at middle age, and is very rare. It was first 
described by Devergie.* The causes are obscure. 

Pathology. — From the investigations of Hans Hebra f it appears 
that in the earlier stage of the disease, and perhaps in milder 
cases throughout, while there is a decided cell infiltration in the 
various strata of the corium and rete, yet the general form of the 
papilla?, together with the normal appearance of the glands and 
hairs, is preserved. In severe and long-continued cases, however, 
the changes in the cutaneous tissues are decided. An abundant 
proliferation of cells is found in all the strata, but more especially 
immediately under the epidermis. This is somewhat thickened, 
and underneath follows a thin layer of compressed rete cells abun- 
dantly interspersed with infiltration cells. Below this is a thick 
flattened layer of connective tissue somewhat less filled with infil- 
tration cells, and below this still a layer of thick elastic tissue thrice 
the thickness of the three upper layers just described, and contain- 
ing a deposit of yellow pigment granules. The papillse are en- 
tirely obliterated, the layers described lying flat upon one another. 
The bloodvessels distributed to the sub-epidermal tissues are sur- 
rounded by abundant cell infiltration. Sweat and sebaceous glands 
are almost or entirely wanting. The scanty hairs show cell infil- 
tration about their sheaths. 

Diagnosis. — The disease is liable to be confounded with eczema 
squamosum, psoriasis, lichen ruber, and pemphigus foliaceus. It 



* Traite pratique des Maladies de la Peau, p. 442. Paris, 1857. 
f Viertelj. f. Derm, und Syph., 4 Heft, 1876. 



326 



INFLAMMATIONS. 



bears a resemblance to all of these affections, but can scarcely be 
confounded with them if the characters be borne in mind. It 
differs from erythematous and squamous eczema in its superficial 
nature and universal distribution; in the absence of marked thick- 
ening of the skin ; in the peculiar formation and character of the 
scales, their rapid production and abundance ; and, finally, in the 
absence, as a rule, of itching and burning. Psoriasis rarely invades 
the whole or even the greater portion of the surface ; pityriasis 
rubra, as a rule, attacks the whole surface uniformly. The scales, 
moreover, are different in these two diseases, and are usually alone 
sufficient to establish the diagnosis. In psoriasis there is always 
more or less thickening of the patches; and, where the process is 
active, there is considerable itching or burning. Pityriasis rubra 
may be mistaken for pemphigus foliaceus, which it may resemble 
as regards distribution and the character of the exfoliation. In 
pityriasis rubra, however, there is no attempt at the formation of 
bulla?, the process being always dry. 

Treatment.— Treatment in most cases has been unsatisfactory. 
It should be directed upon general principles, and must vary 
somewhat with the case under consideration. Locally, inunctions 
with bland oily substances are indicated. The remedies should be 
soothing rather than stimulating. Strong remedies are seldom 
tolerated. Internally, saline aperients, diuretics, iron, quinine, and 
arsenic may be prescribed, as may seem indicated.* 

Pityriasis Rosea.— This disease was first described by Gibert,f 
and was so named by him. Later, Bazin,| Hardy, §and Horaud || 
referred to it under the name of " pityriasis maculata et circinata." 



* Interesting eases of this disease have heen reported by McGhie, Glasgow 
Med. Jour., 1858, vol. v. p. 431 ; Wilks, Guy's Hospital Reports, 1861, p. 310 ; 
Wilson, Med. Times and Gaz., Jan. 29, 1870; Benson and Smith,' Dublin 
Jour, of Med. Sci., vol. xlix. p. 451 ; Tilbury Fox, Lancet, Jan. 1874, p. 294; 
G. H. Fox, Arch, of Derm., July, 1875, p. 296 ; Finny, Dublin Jour, of Med! 
Sci., March, 1876 ; Hans Hebra, loc. cit. ; and McCall Anderson, Brit. Med. 
Jour., Dec. 8, 1877. 

f Maladies de la Peau, 3e edit., p. 402. Paris, 1860. 

X Affections cutanees de nature arthritique et dartreuse p 200 Pari- 
1868. 

\ Lecons sur les Maladies de la Peau, p. 204. Paris, 1868. 

|| Annales de Derm, et de Syph., t. v. No 5 (1875-76). 



PITYRIASIS RUBRA. 327 

It has also been recognized in Germany by Behrend.* I have 
elsewhere described it at length. f It is an inflammatory disease, 
of a mild type, occupying chiefly the trunk, more paricularly 
the subclavicular, lateral thoracic, and scapular regions, character- 
ized by discrete or confluent macular or slightly raised maculo- 
papular lesions, usually the former, varying in size from a pin-head 
to a silver half-dollar. They are usually the size of a split pea 
or silver dime. They are rounded, circular or ovalish, sharply 
circumscribed, superficially seated, and are either on a level with 
the surrounding skin or slightly elevated, or, on the other hand, 
depressed, so that their border often presents the appearance of 
a ring. In color they are generally rosy or pale red, with later a 
more or less yellowish or tawny tint; in other cases the red is 
deeper and the coloring mottled. The surface of the patches is 
always dry and more or less scaly, the desquamation being furfu- 
raceous, and, as a rule, scanty, similar to that of tinea versicolor 
and tinea circinata. It is usually more pronounced about the 
borders of the lesions, which incline to heal in the centre and to 
spread on the periphery. The skin is but little thickened, and 
sometimes feels almost normal when taken between the fingers. 
The subjective symptoms are variable; in some cases there is 
decided itching, especially noticeable when the patient is over- 
heated, while in other instances the individual is scarcely made 
aware of the existence of the eruption. 

The course of the disease in my experience is quite uniform as 
to duration, the lesions usually lasting from one to three months, 
when spontaneous involution sets in, recovery taking place, with 
increased desquamation and pigmentation, within a fortnight or a 
month. The onset of the disease may be sudden or gradual, new 
lesions appearing from day to day or from week to week. They 
are in most cases numerous and situated close to one another, 
in which event as they enlarge they incline to coalesce, forming 
variously sized and shaped, often large, macular or circinate 
patches. Thus, as in tinea versicolor, the whole chest or the neck 
may be invaded by a continuous or broken-up patch. 

Horand seems to have encountered the disease only in children. 



* Berl. Klin. Wochenschr., ISTo. 38, 1881. 
f Amer. Jour, of Med. Sci., Oct. 1880. 



328 INFLAMMATIONS. 

I have met with it chiefly in adults, of both sexes, who have been 
in average general health. The disease is a benign one, and is not 
contagious. It is rare. It may be confounded with tinea circinata, 
tinea versicolor, seborrhcea corporis, lichen ruber, psoriasis, and 
syphilis, more especially with the two first named, which it may 
closely resemble. It has the general appearance and the course 
of a vegetable parasitic affection, but microscopic examinations of 
the scales fail to show any fungus. In all of the cases encoun- 
tered by me the disease was well marked and conspicuous, in- 
vaded large tracts, and ran a course terminating in spontaneous 
recovery. 

Dermatitis Exfoliativa. — Under the names "dermatitis 
exfoliativa,"* "general exfoliative dermatitis,"! "recurring ex- 
foliative dermatitis,"| "desquamative scarlatiniform erythema,"§ 
"recurrent acute eczema,"|| "acute general dermatitis/'^ "re- 
current exfoliative erythema,"** cases representing unusual and 
in some instances grave forms of disease have been described, 
which are to be distinguished from the recognized varieties of 
eczema and psoriasis, and from pityriasis rubra and pemphigus 
foliaceus. Eruptions of a similar character may also follow wounds 
and injuries, as in the cases of scarlatiniform rashes reported by 
Sterling.ft This observer classes them as vaso-motor eruptions, 
and regards them as similar to the rashes which occur in recently- 
parturient women from the third to the fifth day after confinement.!! 
Much diversity of opinion exists as to the true nature of the cases 
which have been thus described, and it is difficult to determine 
from the reports whether they illustrate the same process or differ- 



* Wilson, Diseases of the Skin, London, 1867. 

f Baxter, Brit. Med. Jour., vol. i., 1879; also Percheron, Etude sur la 
"dermatite exfoliatrice generalisee," Paris, 1875; and Jamieson, Edin. Med. 
Jour., April, 1880. 

% Bulkley, Arch, of Derm., July, 1878. 

I Fereol, Bull. Gen. de Therap., Feb. 15, 1876. Abstract in Phila. Med. 
Times, March 18, 1876. 

I| Fagge, Guy's Hospital Reports, 3d Ser., vol. xiii., 1868. 

fl Pye-Smith, Guy's Hospital Reports, 3d Ser., vol. xxii., 1877. 

** G. H. Fox, Arch, of Derm., July, 1879, p. 264. 

ft St. George's Hospital Reports, vol. x., 1879. 

++ See Kidd's article on this subject, Dubl. Jour, of Med. Sci., April, 1880. 



DERMATITIS EXFOLIATIVA. 329 

ent diseases. Fagge's case, for example, was regarded by liim as 
being a doubtful one of eczema, but was called so (with a mark 
of interrogation) for want of a better name. It seems to me, 
however, not to have been an eczema, but rather an example of a 
peculiar and rare disease, which for the present we may designate 
dermatitis exfoliativa, an instance of which I have observed. 

Bulkley's case shows doubtless the same disease in a localized 
form, the hands and feet only having been invaded. Fereol's 
case was a general scarlatina-form exfoliative dermatitis accom- 
panied with slight febrile disturbance, and followed by free des- 
quamation, which in the several relapses was always entire, and 
was probably another variety of the same disease. I have seen 
one marked instance of this form of disease which at first closely 
resembled scarlatina in the cutaneous symptoms, but which, view- 
ing it as a whole, could not possibly have been confounded with 
eczema, psoriasis, pityriasis rubra, or pemphigus foliaceus. In 
passing, I would direct attention to the more than probable rela- 
tionship pathologically between certain cases of localized dermatitis 
exfoliativa (as, for example, Bulkley's case) and some cases of the 
so-called cheiro-pompholyx which have been reported. 

In all of the cases entitled to the name dermatitis exfoliativa the 
process, whether localized or generalized, was characterized by an 
acute erythematous, more rarely vesicular or bullous, inflamma- 
tion, with more or less marked febrile disturbance, accompanied 
or followed by varying degrees of desquamation or exfoliation of 
the epidermis, and marked by a tendency to relapses.* 

* Eitter (Centralzeit. fiir Kinderheilk., Oct. 1, 1878 ; also Viertelj. fur Derm, 
und Syph., Heft 1, 1879) describes, with the name " exfoliative dermatitis of 
nursing children," a non-contagious disease which makes its appearance from 
the second to the fifth week, characterized by redness and desquamation, at 
first local but later general, with thickening of the epidermis and the exuda- 
tion of a thin layer of fluid beneath the same. The epidermis was thrown off 
in large masses, leaving the skin of a dark-red color, presenting an appearance 
like an extensive burn. The hands and feet were particularly affected, from 
which regions the epidermis peeled in large patches. Several varieties of the 
disease were observed, one in which vesicles and blebs formed. Desiccation 
occurred rapidly. The disease is differentiated by Eitter from eczema, but 
it would seem to have a relationship to it. It was observed chiefly at the 
Foundling Asylum in Prague, where in ten years nearly three hundred 
cases were noted. The mortality was fifty per cent. I have never encoun- 
tered the disease. 



330 INFLAMMATIONS. 



FURUNCULUS. 

Syn., Furuncle ; Boil; Germ., Blutschwar ; Fr., Furoncle. 

FuRUNCULUS IS A DEEP-SEATED, INFLAMMATORY DISEASE, CHARAC- 
TERIZED BY ONE OR MORE VARIOUSLY SIZED, CIRCUMSCRIBED, ROUNDED, 
MORE OR LESS ACUMINATED, FIRM, PAINFUL FORMATIONS, USUALLY 
TERMINATING IN CENTRAL SUPPURATION. 

Symptoms. — Furunculi may occur singly, or, as is oftener the 
case, in numbers. Commonly, they appear in successive crops, two, 
three, or half a dozen making their appearance at the same time, 
to be followed after they have disappeared by another invasion 
(furunculosis). They are generally isolated, and are apt to occur 
at points distant from one another. The lesion first shows itself 
as a small, rounded, imperfectly defined, reddish spot, situated in 
the true skin ; even at this stage it is usually highly inflammatory 
and tender to the touch. It increases in size gradually, and be- 
comes slightly raised, its central point exhibiting inclination to 
suppurate. In about a week or ten days it arrives at its full de- 
velopment. When mature, it consists of a slightly raised, rounded 
and pointed, inflammatory formation, its centre being marked usu- 
ally by circumscribed suppuration, termed the "core." At times 
no core forms, when it is called a "blind boil." In size it is ex- 
tremely variable; it may be as small as a split pea, or as large as 
a silver half-dollar. Its color is deep red, which is more intense 
towards the centre, gradually fading away on the periphery, in 
the form of an areola. The pain is of a dull, throbbing nature, 
and is usually worse at night. It increases in intensity until sup- 
puration and discharge take place, after which it subsides. Re- 
markable tenderness is also a characteristic of the boil, the 
slightest contact causing suffering. 

The furuncle may attack any portion of the body, no region 
being exempt. It has preference, however, for the face, ears, neck, 
back, axillae, nipples, buttocks, anus, perineum, scrotum, labia, and 
legs. Constitutional disturbance may be present, which may be 
slight or severe, its extent depending upon the nature and amount 
of the inflammation. The adjoining tissues may be sympathet- 
ically affected, as manifested by soreness and pain; neighboring 
glands may also be enlarged. Furunculi are sometimes noted 



FURUNCULUS. 331 

to occur as a complication with other cutaneous diseases, as, 
for example, eczema, when they may partake of the nature of 



Etiology. — The causes which give rise to boils are various. 
Frequently they are the result of a low and depraved state of 
the system, induced by general debility, excessive fatigue, nervous 
depression, improper food' and exercise, irregularity of the func- 
tions of the body, and the like. Not rarely they are encountered 
in the course of other diseases, as in chlorosis, fevers, and similar 
conditions, when they may appear in numbers ; also in connection 
with diabetes, and sometimes with uraemia and septic pyaemia. 
Their appearance is to be viewed as being dependent upon a dis- 
ordered state of the system. They may occur at any time of life, 
but are more common in youth and old age. In some cases the 
causes are local, depending upon friction, contusions, or other in- 
juries; but, as a rule, they result from such causes only in those 
cases where there is a predisposition to their development. 

Pathology. — The furuncle has its seat in the corium and deeper 
tissues. According to Kochmann,* it may begin in a sebaceous 
gland lying in the corium near the surface, or may originate in a 
sweat gland or hair-follicle lying deeper, even in the subcutane- 
ous connective tissue. The latter variety is the connective-tissue 
furuncle, formerly so called. It always has a gland as a centre of 
origin, and never begins in the meshes of the corium. Beginning 
in a sweat gland, as usually encountered in the axillae, around the 
nipples, and about the anus or perineum, it has been described at 
length by Yerneuil f and Bazin,J with the name "hydradenitis," 
but it differs from the commoner form merely in being deeper- 
seated. The boil is an inflammation of a peculiar type, running a 
more or less definite course. It begins as a small roundish spot, 
which increases in size until certain dimensions are attained, 
when it undergoes suppurative change, resulting in the formation 
of a central point, or core, composed of the tissue of the gland in 
which the furuncle originated, which, together with pus, is cast 



* Beitrag zur Lehre von der Furunculosen Entzundung. Archiv fur Derm, 
und Syph., Heft 3 u. 4, 1873. 
f Arch. Gen. de Med., 1854. 
X Affections generiques de la Peau, vol. ii. p. 319. Paris, 1865 



332 INFLAMMATIONS. 

off. It shows no disposition to become diffuse, being always a 
circumscribed inflammation. After the discharge of the core, a 
cavity of more or less depth remains, showing the tissues around 
it to be hard and infiltrated ; after a few days or a week it fills 
up by granulation, leaving a cicatrix, which is often permanent. 
The central point or core, when thrown off, is composed of a 
whitish, tough, pultaceous mass of dead tissue, varying in size 
with the extent and depth of the inflammation. 

Diagnosis. — The symptoms of furuncle are so well known that 
error in diagnosis can scarcely occur. The affection differs from 
anthrax, in that it possesses only one point of suppuration, the 
core, whereas in the latter disease this feature is multiple. The 
furuncle is, moreover, rounded in form, and somewhat acuminate 
in shape; the carbuncle may be rounded or ovalish in outline, but 
is flat. Furuncle is small, being seldom larger than a walnut; 
carbuncle varies in size from a large coin to five or ten inches in 
diameter. Furuncle is exquisitely sensitive and painful to the 
touch ; carbuncle is not particularly sensitive to the touch, the 
pain being of a spontaneous nature. Furuncles generally occur 
in numbers, either at the same time or in the form of successive 
crops ; carbuncle is almost invariably single. 

Treatment. — Constitutional and local treatment are both called 
for, especially the former, the object being to prevent the forma- 
tion of new lesions and at the same time to care for those which 
exist. Each case demands special study, with the view of ascer- 
taining the cause of the affection. The functions, if disordered, 
are to be regulated by appropriate means. Tonics may in almost 
all instances be directed w r ith good result. The saline aperient 
tonics mentioned in connection with acne may often be prescribed 
with advantage, alone or in connection with other treatment. Ar- 
senic, iron, quinine, and the mineral acids are all useful remedies. 
Arsenic, in from two to four minim doses three times daily, will 
be found serviceable in many cases. The sulphite and hyposul- 
phite of sodium, in fifteen or thirty grain doses, every two or 
three hours, are valuable remedies, to which many cases will yield. 
The sulphides, especially the sulphide of calcium, in doses of an 
eighth of a grain or a quarter of a grain every two hours, recom- 
mended by Ringer, will likewise be found valuable. In some 
cases liquor potassse, in ten to twenty minim doses, with a bitter 



FTJRUNCULUS. 333 

infusion, as quassia or cinchona, may be prescribed with benefit. 
Fresh yeast, in tablespoonful doses three or four times daily, is 
also said to be efficacious. Piffard speaks well of the syrup of the 
hypophosphites of lime, iron, soda, and potassa; while Hardy 
states that he has obtained good results from tar- water, taken to 
the extent of a quart in the twenty-four hours. The prepara- 
tions of phosphorus are also recommended. The diet should be 
generous, embracing the most nutritious articles of food. In 
broken-down subjects the judicious use of red wine and malt 
liquors will prove beneficial. Hygienic measures also play an 
important part in the treatment. Change of air is desirable, 
and is sometimes followed at once by manifest benefit. 

In the first stage of the disease the lesion may sometimes be 
aborted by the use of caustics applied to the forming core, for 
which purpose carbolic acid, nitrate of silver stick, acid nitrate of 
mercury, nitric acid, or the actual cautery may be employed. Car- 
bolic acid is the best remedy, and may be used to the apex of the 
boil pure, or with an equal part of glycerine. Injection of car- 
bolic acid, two or three drops of five per cent, solution, into the 
apex of the boil is highly recommended by Weber-Liel and others. 
Later, hot poultices of flaxseed meal, applied continuously until 
the core has been cast off, afford the most relief. Cold-water 
dressings may also be employed in the first stage. 

Prognosis. — Where they tend to appear in crops they are gen- 
erally rebellious to treatment. When they appear in numbers, 
the general health of the patient is usually impaired ; in such 
cases the treatment should be energetic, a change of air and trav- 
elling often proving of value. 

Under the names of Aleppo Boutost, Boil or Evil, Delhi 
Boil, and Biskra Bouton, certain diseases resembling one another 
have from time to time been described by writers. The first of 
these is found at Aleppo, Bagdad, and the surrounding country ; 
the second in India; and the third in Algeria and elsewhere along 
the coast of Africa. They are epidemic in these countries. Much 
confusion has long existed as to their true nature. They have 
been described as being allied to furuncle, although possessing a 
much more chronic course. They are characterized at first by the 
formation of a papule or tubercle, which soon becomes a pustule, 
finally terminating in ulceration, followed by a cicatrix. It is 



334 INFLAMMATIONS. 

highly probable that these three diseases are identical, but modified 
by nationality, climate, and other causes. 

For an account of the diseases, in detail, I would refer the 
reader to the valuable writings of Tilbury Fox and Farquhar,* 
and Geber,f upon the subject. The latter observer remained some 
time in Aleppo for the purpose of studying the disease, and arrived 
at the conclusion that all the cases of so-called Aleppo Boutou 
were modified forms of syphilis, lupus, or scrofula. 



ANTHRAX. 

Syn., Carbunculus ; Carbuncle; Germ., Brandschwar. 

Anthrax is a firm, more or less circumscribed, painful, 
deep-seated inflammation of the skin and subcutaneous 
structures, variable as to size, terminating in a slough. 

Symptoms. — The disease is usually ushered in with a chill, fever, 
and other symptoms of general disturbance. The skin becomes 
hot and painful, and there forms a firm, flat, more or less circum- 
scribed inflammation, reddish or violaceous in color, extending 
deeply into the subcutaneous tissues. It is painful, and is gen- 
erally accompanied with a burning sensation. Within a fortnight 
it will usually have arrived at its height, and then consists of a 
deep-seated, circumscribed, brawny inflammation of a dark-red or 
violaceous color. The tissues now begin to soften, and the skin 
becomes gangrenous, breaking down at numerous points, forming 
perforations, through which centres of suppuration may be noticed, 
either as whitish fibrous plugs, or as cavities, from which a yel- 
lowish, sanious fluid oozes. The surface has a cribriform appear- 
ance, being perforated like a sieve. The whole mass of tissue 
results in a slough, which comes away as soon as detached, this 
process taking place either at once or by degrees, pieces being cast 
off from day to day. A large, open, deep ulcer, with firm or hard, 
everted edges and uneven base, results, which granulates slowly, 
leaving a more or less pigmented, permanent cicatrix. 



* Loc. cit., p. 241. Also " On Certain Endemic Skin and other Diseases of 
India and Hot Climates generally," by Tilbury Fox, M.D., and T. Farqubar, 
M.D. London, 1876. 

f Yiertelj. fur Derm, und Syph., Viertes Heft, 1874. 



ANTHRAX. 335 

The course of the disease varies according to the age of the 
patient, vitality of the part, recuperative power, and other circum- 
stances. Its duration will depend upon the size; when large it 
may last from four to six weeks. It is usually single. Its favorite 
seats are upon the back of the neck, shoulders, back, and buttocks. 
It is a serious disease, and when extensive, especially in the elderly, 
may terminate fatally. Boils are liable to appear about the borders 
of carbuncle, either singly or in groups. It sometimes occurs with 
diabetes. 

Etiology. — The causes are not well understood. They are doubt- 
less of a nature similar to those which give rise to furuncle. The 
disease is generally noted to occur in those who are broken down 
in general health, whatever be the cause of this condition. It 
attacks the abstemious as well as the intemperate. It is usually 
encountered in middle and old age, and is more often observed in 
men than in women. 

Pathology. — The pathological anatomy of carbuncle is similar 
to that of the more deeply seated variety of furuncle. The disease 
has been aptly likened to a group of furuncles ; but, as a process, 
it is much more destructive than the boil. Death of tissue is 
limited to one point in furuncle, while in anthrax it is diffuse. 
Beginning in a number of centres formed by the sebaceous and 
sweat glands of the locality, numerous points being simultaneously 
attacked, the inflammation extends downwards towards the looser 
meshes of the connective tissue, and then in a horizontal direction, 
involving the intervening tissues in the destructive process, the 
whole surface invaded terminating in gangrene and a slough. 
Warren,* in a study of the pathology of the disease, has shown 
that the pus ascends by way of the columnar adiposse to the hair- 
follicles, by the side of which it finally " points." The process 
frequently extends down to the fascia? and muscles. 

Diagnosis. — The disease will be readily distinguished from fu- 
runcle by its size, flatness, course, multiple points of suppuration, 
and the character of the slough. It may be mistaken in its early 
stage for erysipelas ; later, however, this error would be dissipated 
by its circumscribed character, hardness, and pain. 

Treatment. — The treatment should be both constitutional and 

* Bost. Med. and Surg. Jour., April 17, 1877. 



336 INFLAMMATIONS. 

local, the former of which should be conducted upon general prin- 
ciples. Supporting measures are demanded in the majority of 
cases, when the most nourishing diet, together with milk, eggs, 
and whiskey or red wine, is to be freely administered. Tincture 
of the chloride of iron and quinine are the two remedies from 
which most benefit is to be looked for. The latter should be given 
in full doses, from ten to twenty-five grains for each dose, at inter- 
vals of twelve or twenty-four hours. Ringer speaks highly of the 
sulphides, as in the case of furuncle. The sulphite or hyposul- 
phite of sodium may also be used. Anodynes, especially opium, 
are useful for the purpose of insuring rest at night. All measures 
calculated to improve the general condition should be instituted. 

Local treatment may be referred to. When the carbuncle is 
hard and painful, crucial incisions will at times afford relief. 
The majority of cases, however, do equally well or better without 
cutting.* The wound may be dressed with carbolized oil in the 
strength of one to five or ten. Hypodermic injections of carbolic 
acid may also be practised, as in furuncle, the solution being of 
five or ten per cent, strength. Agnew speaks well of painting 
cantharidal collodion around the carbuncle, in the form of a 
broad zone, the effect of the blister being to relieve the tension. 
A similar method of treatment consists in painting the lesion re- 
peatedly with tincture of iodine. Ether spray is well spoken of by 
Zimberlin.t Carbolic acid and glycerine, equal parts, may also be 
applied. Various dressings have been recommended. Hebra 
speaks in favor of cold applications (cloths wrung out in ice-water 
or ice-bags) in the early stage, stating that more relief is to be 
obtained from this source than from poultices. Warm fomenta- 
tions are, however, to be employed as soon as suppuration has 
begun ; they tend to relieve the tension of the tissues, and hasten 
the discharge of the slough. The poultices may be made of flax- 
seed meal, and should be changed frequently. The parts should 
be kept scrupulously clean, the discharge being removed as soon 
as it makes its appearance on the surface. The slough should be 



* In corroboration of this view, see a clinical lecture on the treatment of 
carbuncle, by Paget, Clinical Lectures and Essays, London, 1875; also Agnew, 
Principles and Practice of Surgery, Phila., 1881. 

f Schmidt's Jahrbuch, No. 1, 1881. 



ANTHRAX. 337 

carefully picked out with the forceps as soon as detached. For 
the purpose of removing the pus and the slough dry cupping may 
be practised, as recommended by Leitner.* The operation may be 
repeated several times, and is said to afford much relief. The 
ulcer should be washed with carbolic acid, one part to eight or 
twelve parts of water. The ulcer which remains is to be treated 
in the manner of a simple ulcer. 

Prognosis. — This should be guardedly expressed. In the early 
stage of the disease it is impossible to state to what extent the car- 
buncle will spread ; it may be two or three or six inches in diam- 
eter. A fatal termination is liable to take place, especially in 
elderly people who are broken down in health ; but the mortality 
is not so great as is commonly supposed. 

In connection with the subject of phlegmonous inflammations 
are to be mentioned several diseases affecting the skin and deeper 
tissues, which are produced through infection with animal poisons.f 

Poisoned Wounds. — Wounds of this character are produced 
by numerous insects as well as by animals. The symptoms may 
be local or constitutional, but are commonly the former. A num- 
ber of small insects, as certain kinds of midges and flies, the mos- 
quito,! A ea ? an d bed-bug, cause lesions upon the skin, which vary 
in kind and degree according to the susceptibility of the individual. 
The bites of these insects at times give rise to appearances resem- 
bling urticaria and purpura. Bees and wasps not infrequently 
occasion considerable cutaneous disturbance by their stings, and 
in rare cases constitutional disorder or even death. The bites of 
many insects and spiders, as, for example, the scorpion, and rep- 
tiles, met with in hot climates, are extremely poisonous, and cause 
various lesions of a more or less inflammatory character. 

The treatment of bites of venomous snakes consists in stimu- 
lating freely with alcohol, usually in the form of whiskey, and in 



* Trans. Med. Assoc, of Georgia, 1877. 

f For a more complete description of these diseases the reader is referred 
to Agnew's Principles and Practice of Surgery, vol. i., Phila., 1878, and to 
Gross's System of Surgery, Phila,, 1872. 

% See a paper " On the protection acquired hy the human skin and other 
tissues against the action of certain animal poisons after repeated inoculations," 
by Dr. J. 0. White, Bost. Med. and Surg. Jour., Nov. 9, 1871. 

22 



338 INFLAMMATIONS. 

the use of carbonate of ammonia by the mouth or by hypodermic 
injection. Employed by the latter method, fifteen or thirty minims 
of a solution containing a drachm to the ounce of water may be 
administered repeatedly. Lacerda, of Brazil, recommends hypo- 
dermic injections of a solution of permanganate of potash, using a 
fluidrachm of a one per cent, solution, which he states is usually 
effective within five minutes. Stings of insects are best treated 
with ammonia and lime, a few grains of quick-lime dissolved in 
water being a remedy always at hand. Dilute carbolic acid, sugar 
of lead solution, spirit of camphor, salt and water, and wet clay, 
are also remedies of more or less virtue to which reference may be 
made. 

Dissection Wounds. — The symptoms resulting from inocula- 
tion through contact with dead bodies are various ; they may be 
local, confined to the point of inoculation, or they may be general, 
producing severe constitutional disturbance. Usually the disease 
is at the seat of a former abrasion of the skin, as, for example, 
upon the hand, which commences by the formation of a small 
vesicle or pustule upon a hard, inflammatory base, or as a patch 
of infiltration of a reddish or violaceous color. There is at first 
more or less burning or itching, which may be followed by pain, 
usually extending up the arm to the axilla, lymphangitis, and con- 
stitutional svmptoms. The wound as soon as detected should be 
thoroughly washed or sucked and soaked in a solution of chloride 
of zinc or burned with this caustic. 

In other cases the disease is strictly local, the lesion being con- 
siderably indurated, circumscribed, and sometimes painful. The 
epidermis may become thick and fissured, the sore secreting a thin 
or thick fluid, resulting in a crust. In other cases the disease 
begins in the form of a papule or tubercle, which may be followed 
by a more or less desquamative papillary growth, the lesion as- 
suming an indolent tubercular or warty character. Wilks * de- 
scribes this lesion with the name " verruca necrogenica ;" it is also 
known as "dissection," "anatomical," and "post-mortem" tuber- 
cle. Its usual seat is about the fingers and joints. The process, 
whether in the form of a patch of diffused or circumscribed infil- 
tration, or as a tubercle, assumes usually a chronic course, and is 

* Guy's Hospital Reports, 3d Ser., vol. viii. 



ANTHRAX. 339 

generally rebellious to treatment. Stimulating ointments, as the 
mercurials, especially the oleate of mercury ten or twenty per cent, 
strength, nitrate of silver, caustic potash, and acetic acid, will be 
found the most efficacious remedies. 

Pustula Maligna. — Malignant pustule, called by the French 
"charbon," presents features similar to those seen in dissection 
wounds of a malignant type. The disease is due to the inoculation 
of a peculiar, virulent poison generated in cattle suffering from a 
disorder known by the name of murrain, or charbon. After in- 
oculation, which usually occurs about the hands of those who 
have to deal with cattle and hides, the period of incubation is very 
brief, often only a few hours, when the part is attacked with pain, 
burning, and itching, followed by the formation of a vesicle or 
pustule, with an extensive, hard areola; the pustule increases to 
the size of a coin, and soon breaks into an unhealthy discharging 
ulcer. The constitutional symptoms are usually severe, the patient 
not infrequently succumbing. 

Equinia, called also Glanders and Farcy, may be defined 
as a malignant, contagious disease, derived from the horse, mani- 
festing itself by grave constitutional symptoms, inflammation of 
the nasal and respiratory passages, and a deep-seated, pustular, 
hemorrhagic, ulcerative form of eruption. After inoculation has 
occurred, there is a period of incubation, varying from a few days 
to a week, when marked symptoms of general disturbance, pros- 
tration, and rheumatic pains manifest themselves, followed by a 
peculiar eruption composed of pustules, similar in form ,to those 
of variola or vaccinia, containing a thick, yellowish product 
mingled with blood. At times the eruption is of a tubercular 
or vegetating nature ("farcy buds"); these rapidly disintegrate 
and result in extensive ulcers, accompanied by hemorrhage and 
gangrene. The lymphatics become inflamed, erysipelatous patches 
and bullae form here and there, which break down into suppu- 
rating and bleeding ulcers. Hard and painful tumors, of various 
sizes, also appear, which rapidly soften into deep abscesses. The 
skin over the whole body becomes oedematous, swollen, and ecchy- 
motic. The nasal passages and the respiratory tract are affected 
in a most virulent manner. A thick, yellowish, bloody secretion 
flows from the nostrils; the mouth and throat become inflamed 
in patches; the glands enlarge; ulceration and gangrene of the 



340 INFLAMMATIONS. 

mucous surfaces take place as upon the skin, and the patient suc- 
cumbs. It is said that the two sets of symptoms, those of the 
mucous membrane and those of the skin, may or may not occur 
in the same subject. The disease always originates in the horse. 
It is highly contagious, and may be contracted either by means of 
direct contact or through the medium of the air. The disease is 
rare. There is no specific treatment. 

DERMATITIS. 

Under this term, signifying simply inflammation of the skin, 
without reference to its cause or clinical features, I have grouped 
a number of inflammatory conditions similar as to their pathologi- 
cal anatomy, produced for the most part by external agencies, as, 
for example, heat, cold, cutaneous irritants, caustics, etc. Affections 
of this character are of every-day occurrence, and, as they happen 
to be superficial or deep-seated, fall into the domain of surgery 
proper or of dermatology. The lesions met with vary according 
to the nature of the cause, the intensity of its action, the suscepti- 
bility of the skin of the individual, and other circumstances. In 
the first stage there exists erythema of various grades, which may 
remain as erythema or may pass into other pathological conditions, 
as vesicles, pustules, blebs, or gangrene. The usual clinical signs 
of inflammation — redness, heat, swelling, pain, or itching — are all 
present in a more or less marked degree. The affection may be 
either diffused, as, for example, in dermatitis from poisons, or 
circumscribed, as in traumatic dermatitis. The forms most fre- 
quently encountered may be referred to under the heads of the 
causes which produce them. 

Dermatitis Traumatica. — Here are found all those active 
or passive inflammatory states which exist as the result of direct 
violence to the skin ; they include contusions, and other injuries of 
a similar character, as, for example, the irritation to the surface 
arising from ill-fitting garments, shoes, and other articles of wear. 
The various conditions referred to in considering the simple ery- 
themata may, under adverse circumstances, likewise terminate in 
inflammation, varying as to degree. As stated in speaking of 
erythema simplex, the dividing line between hyperemia and in- 
flammation cannot be drawn sharply ; the former frequently bor- 



DERMATITIS. 311 

ders on the latter without the process becoming inflammation in 
so decided a degree as to be worthy of this name. 

Excoriations constitute to the dermatologist one of the most 
important varieties of traumatic dermatitis. They are superficial 
losses of substance of the epidermis and corium, accompanied by 
more or less inflammation, the result usually of scratching on the 
part of the patient. Lesions of this kind, of a marked inflam- 
matory character, are observed in connection with scabies, and 
pediculosis of the body, where the skin is lacerated extensively 
and the lesions followed often by considerable thickening and pig- 
mentation. 

Dermatitis Venenata. — Under this head are included nu- 
merous inflammatory conditions of the skin, resulting from con- 
tact with substances which act deleteriously upon this organ. The 
inflammation is of all grades. According to the virulence or 
concentration of the poison and the susceptibility of the skin, will 
the lesions be of an erythematous, vesicular, pustular, or bullous 
character. In the vegetable kingdom certain plants are known to 
possess properties of a poisonous or irritant nature when brought 
in contact with the skin ; among these, rhus venenata, rhus toxico- 
dendron (commonly known as, respectively, poisonous sumach or 
dog-wood, and poison ivy or oak), nettle, mezereon, and arnica* may 
be mentioned as being productive of most mischief. The rhus 
family exert a particularly deleterious influence upon the skin.f 
Contact, or, in some cases, proximity to the plants even, is sufficient 
to cause the affection. The poison is an exceedingly volatile acid, 
— toxicodendric acid, — which was discovered in the toxicodendron 
by Prof. Maisch, of this city. 

All persons, however, are not equally susceptible to the influence 
of the acid. Some are not affected at all, being able to handle the 
plants with impunity; others suffer but slightly, and after contact 
only ; while not a few are attacked by a violent inflammation of 
the skin, varying in degree from an erythematous condition to 
vesiculation, accompanied with swelling, heat, and serious disturb- 

* See a paper by J. C. "White on ' ' The poisonous action of tincture of arnica 
upon the skin," in the Bost. Med. and Surg. Jour., Jan. 21, 1875. 

f See an article " On the action of rhus venenata and rhus toxicodendron 
on the human skin," by J. C. White, in the New York Med. Jour., March, 
1873. 



342 INFLAMMATIONS. 

ance. Individuals are met with who are so susceptible as to be 
affected by beiug in the neighborhood merely of the plants. The 
poison is readily conveyed by means of the hands, the parts usu- 
ally first attacked, to other portions of the body, and it is in this 
manner that the eruption generally spreads. The face and geni- 
talia, parts liable to be handled, are frequently the seat of the dis- 
ease. The poison, as a rule, acts quickly, a few hours sometimes 
being sufficient to cause symptoms of cutaneous derangement; 
in other cases several days may elapse before marked symptoms 
develop themselves. 

The eruption may be either of an erythematous or of a vesicu- 
lar character, usually the latter. In typical examples the vesicles 
form rapidly; are remarkable for their irregular form; vary in 
size from pin-points to split peas; and are seated upon an in- 
flamed, more or less cedematous surface. The vesicles may pass 
into pustules, or they may become blebs. When the eruption is 
at its height, swelling, cedetna, heat, and itching are all promi- 
nent symptoms. The hands, arms, face, and genitalia in the male 
are all usually involved, and are sometimes attended by much 
disfigurement. At times the greater part of the surface be- 
comes the seat of disease, showing itself in the form of scattered 
patches; as a rule, the lesions in these cases consist of a mixture 
of erythema and vesicles. The disease pursues an acute course, 
the vesicles rupturing spontaneously or from violence, the fluid 
drying into yellowish crusts. The process may continue from 
one to six weeks, according to the severity of the attack and 
other circumstances, as, for example, treatment. Under proper 
local treatment the majority of cases recover in the course of a 
fortnight. 

The anatomical changes which take place are in all probability 
identical with those which have been noted in connection with 
eruptions produced by croton oil. (See p. 184.) The contents 
of the vesicles possess an acid reaction. The process is an acute, 
simple inflammation of the skin, inclining to spontaneous re- 
covery. Attacking, however, individuals who are predisposed to 
eczema, as must not infrequently happen considering the extent 
to which eczema exists in every community, the course of the 
eruption may become complicated and take on the characters of 
a more or less chronic eczema. It is under these circumstances 



DERMATITIS. 343 

only, it seems to me, that true eczema may be said to follow the 
eruption. 

The treatment should consist of soothing, mildly astringent 
lotions, followed in the later stages by the use of a bland oint- 
ment or a starch dusting powder. The alkalies are all useful. 
Bicarbonate of soda may be dusted on the parts, likewise borax. 
Lotions containing alkalies, as water of ammonia, and solution 
of chlorinated soda, will also be found of value. An excellent 
remedy is a saturated solution of hyposulphite of soda, the parts 
being continually bathed with it. Dilute lead-water is a popular 
and useful remedy. Black wash, employed as a lotion for a quarter 
of an hour at a time, every three or four hours, is a serviceable ap- 
plication. Vegetable astringents, as, for example, decoctions of 
white-oak bark, and of the black alder, are also useful. Towards 
the close of the process, a wash of corrosive sublimate, a grain or 
more to the ounce of water, may be employed, as in the case of 
eczema or scabies of the hands. The best remedy, however, is 
grindelia robusta, in the form of the fluid extract, which may be 
diluted in the strength of one fluidrachm of the extract to four or 
six ounces of water. Bromine is said by Brown to be a valuable 
remedy, in the strength of five or ten drops to the ounce of olive 
oil or petroleum ointment.* Sulphate of zinc and sulphate of 
copper, in the form of dilute lotions, are also recommended. 

Of a similar nature is the inflammation of the skin produced 
by the poisonous aniline and coralline dyes with which under- 
garments are at times colored. Undershirts, drawers, and socks 
dyed with these substances not infrequently cause hyperemia and 
inflammation of the skin, especially when worn in warm weather 
and before having been washed. I have met with cases in women, 
occurring about the feet and legs, where the dye-stuff was found 
to be in the lining of the shoes, the poison having penetrated 
through the stockings. 

Arnica, as has been already stated, also acts injuriously upon 
the skin. The tincture of arnica, a popular though dangerous 
remedy for bruises and wounds, not infrequently causes symptoms 
resembling those produced by the rhus plants. Mustard, cauthari- 

* New York Med. Eecord, April 20, 1878. 



344 INFLAMMATIONS. 

des, savin, tartar emetic ointment, and mezereon are also capable 
of producing mischief upon the skin; when applied carelessly 
the result may be similar to that of the irritants just referred 
to. Croton oil, rubbed into the skin, produces a minute vesicular 
and pustular eruption, accompanied by oedema, swelling, pain, and 
itching, its severity varying with the amount of oil and friction 
used. Mercurial ointment, employed injudiciously in the form 
of inunctions, also occasions at times an eruption similar to that 
of croton oil ; this happens, however, only where the skin is ex- 
tremely susceptible or where the substance is applied indiscreetly. 
The deleterious effects following the application of strong acids, 
as nitric and sulphuric acids, or alkalies and other caustics, are so 
well known as not to require more than mention. Not merely 
inflammation, vesicles, and bulla?, but even gangrene of the skin, 
may take place from the use of such preparations. The various 
irritants which have been enumerated are sometimes employed, 
especially by hysterical women, for the purpose of simulating dis- 
ease, as, for example, nitric acid and cantharides for pemphigus, 
mustard plasters and turpentine for erythema, etc.* 

Dermatitis Calorica. — Both heat and cold call forth inflam- 
matory symptoms, in the form of burns and frost-bites. Burns, 
whether resulting from artificial heat or from the rays of the 
sun, give rise to the same group of symptoms as those produced 
by the causes already referred to. According to the extent of the 
burn will the skin present an erythematous, vesicular, bullous, 
or gangrenous condition. Similar lesions, although usually of a 
much less marked character, are observed in connection with frost- 
bite. 

Dermatitis Gangrenosa. — Gangrenous disease of the skin 
may arise from varied causes, for the most part obscure, and may 
be either idiopathic or symptomatic. It may occur in the form of 
circumscribed or diffused patches. The idiopathic form shows a 
tendency to symmetrical manifestation. It is described as begin- 
ning usually in the form of small or large, circular, erythematous 
reddish or purplish spots, which may be tender and painful or 

* In this connection see an interesting paper by the late Mr. Startin, on 
Feigned Diseases of the Skin, in Brit. Med. Jour., Jan. 8, 1870 ; also an article 
on the same subject by Dr. Fagge, in Brit. Med. Jour., Feb. 12 and March 
26, 1870. 



DERMATITIS. 345 

without sensation. After undergoing a more or less variable 
course they become gangrenous and slough, the process terminating 
fatally or in recovery, the latter event taking place sometimes even 
in the gravest cases. The disease of the skin is usually preceded 
by malaise, feverish n ess, and debility. Dr. Fagge* describes a 
case of circumscribed symmetrical gangrene occurring in a man 
fifty years of age, attacking the lower extremities, in which the 
cutaneous tissues were purplish, in the centre of which surfaces 
there were irregularly-shaped greenish-yellow patches surrounded 
by reddish borders. Somewhat similar cases are recorded by 
Brodie f with the name " a peculiar species of dry gangrene of the 
skin," and by Stock well.! Ilooke§ reports a remarkable case in 
an unmarried lady, thirty-nine years of age. After several days 
of feverish disturbance, a red patch an inch and a half in diameter 
appeared in the sulcus between the left mamma and the ribs, accom- 
panied with a slight pricking sensation, and looking as if the skin 
were irritated by perspiration. A few clays later, a red patch over- 
spread the third part of the mamma ; on the following day a white 
patch the size of a quarter dollar, flat, smooth, and painless, was 
observed in the centre of the redness, and the next day this patch 
had increased to the size of half an orange. The appearance of 
the skin was that of tallow or white wax, and the tissues were 
insensible. During the following four months different parts of 
the integument became in succession gangrenous, thirty-six patches 
being recorded ; in some of these the affection was limited to an 
erythema, which subsided leaving the skin healthy. New patches 
were generally separated from the previous ones by healthy skin. 
Large tracts of skin often became gangrenous with extraordinary 
rapidity. There was well-marked symmetry in the disease. The 
patient recovered. 

Dr. Petri || describes a case in which he himself was the sufferer. 
He had enjoyed good health up to the date of the attack, which 
was preceded by malaise and symptoms of profound general dis- 



* Guy's Hospital Eeports, vol. xiii., 3d Ser., 1868. 
f The Works of Sir Benjamin Brodie, 1865, vol. iii. p. 392. 
% Brit. Med. Jour., Feb. 12, 1870. 
§ Lancet, 1864, vol. ii. p. 486. 

|| Berlin. Klin. Wochenschr., 1879, p. 509. Abstract in Phila. Med. Times, 
Jan. 3, 1880. 



346 INFLAMMATIONS. 

turbance, with high temperature. The eruption consisted of 
numerous symmetrical, hemorrhagic maculae, which at first in- 
creased but later diminished sensibility, amounting to almost com- 
plete anaesthesia. Later, large blebs appeared, sometimes clear, 
at other times bloody, accompanied with extreme exhaustion. At 
the end of six weeks superficial gangrene attacked the arms. Re- 
covery took place in six months. In Rooke's case, local treatment, 
in the earliest stages, consisting of numerous small punctures with 
a lancet, or the application of the tincture of iodine, appeared to 
arrest the process. 

Gangrenous patches may follow nerve lesions or may occur also 
in connection with grave cerebral or spinal diseases, as in the form 
of acute bed-sore, to which Charcot* has called attention, where the 
cutaneous lesions may manifest themselves in so short a period as 
a few days or even a few hours after the nervous symptoms have 
developed. Gangrene of the skin has also been observed in as- 
sociation with diabetes, as in the case recorded by Magnin.f 
EichhoffJ reports a case of multiple cutaneous gangrene due to 
cachexia, occurring in a child, the pathogenesis of the disease re- 
sembling the ordinary bed-sore. Leloir and Dejerinc§ report a case 
due to trophic disturbance, occurring in a young girl of nervous 
temperament. It consisted of patches of superficial gangrene on 
the cheeks, followed by linear scars and "keloid." During three 
years similar patches occurred on the trunk and arms. They 
began by a pricking sensation, slight redness, and a diminution of 
sensibility; within nine hours whitish patches formed, followed 
by sphacelation, ulceration, and scarring. New patches appeared 
every fifteen days. In all cases of gangrene of the skin, and in 
similar forms of inflammations, care should be exercised in ex- 
cluding artificial disease, or that produced by the application 
of irritants and caustics, with a view to deception, such as is 
described by Tilbury Fox || under the name of feigned erythema 
gangrenosum. 

Dermatitis Medicamentosa. — The occurrence of affections 

* Diseases of the Nervous System, New Syd. Soc. Trans., London, 1877. 
f Abstract in Lond. Med. Rec, March 15, 1879. 
% Abstract in Phila. Med. Times, March 26, 1881. 
\ Le Prog. Med., 1881, p. 385. 
II Lancet, Oct. 30, 1875. 



DERMATITIS. 347 

of the skin as a result of the ingestion of medicines is compara- 
tively rare, although such affections may be excited by a variety 
of drugs uuder certain circumstances, chiefly of idiosyncrasy on the 
part of the individual. The following are among the commoner 
drugs which occasionally produce eruptions of different kinds. 
For the sake of convenience I shall refer to them alphabetically.* 

Arsenic. — Arsenical eruptions have been studied by Imbert- 
Gourbeyre,f Hilton Fagge,| and others. The eruption, according 
to these writers, is sometimes papular, resembling erythema multi- 
forme, measles, or the syphilodermata of the face ; in other cases 
it is urticarial. The lesions generally occur upon the face and 
neck ; less frequently upon the hands and elsewhere. When pap- 
ular, they last usually from five to ten days. Occasionally an ery- 
sipelatous rash occurs on the face, and more rarely a pustular or 
bullous eczema-form eruption. A purpuric eruption has also been 
described.! The pustular, ulcerative, and gangrenous conditions 
caused by arsenic are usually due to the external effect of this 
substance, as in laborers in arsenic works and in dyeing establish- 
ments. 

Belladonna, Atropia. — The eruption produced by the in- 
gestion or absorption through the skin of the preparations of bella- 
donna and its alkaloid is striking, and is among the best known 
of the medicinal rashes. The efflorescence is peculiarly liable to 
occur in children, although it is also of not infrequent occurrence 
among adults. It may show itself within a few minutes or hours 
after the ingestion of the medicine, even in the smallest doses, and 
may disappear as rapidly or gradually. It usually manifests itself 
upon the face, neck, and chest ; less frequently over the whole 
surface. In form it consists of erythematous patches, or of a 
bright scarlatinoid rash, accompanied by dryness of the throat, 
and headache. There is usually no fever, nor does it give rise to 
itching or desquamation. Cases have been reported by Lusana,|| 



* The author is indebted to his friend Dr. Van Harlingen for valuable 
assistance in the preparation of this article. For further information on the 
subject the reader is referred to an exhaustive paper by Dr. Van Harlingen 
in the Archives of Dermatology, Oct. 1880. 

f Histoire des eruptions arsenicales, Moniteur des Hopitaux, 1857, p. 3017 

% Med. Times and Gaz., Feb. 29, 1868. 

\ Imbert-Gourbeyre, loc. cit. || L'Union Med., 1854, p. 757. 



348 INFLAMMATIONS. 

Jolly,* Berenguier,f and Dreyfou?4 J - Gr. Wilson § reports a 
case where the characteristic eruption was brought out by the 
inunction of the breast with extract of belladonna. It may be 
mistaken for scarlatina. 

Bromine, Bromides. — The eruption due to the bromide of 
potassium ordinarily assumes the form of scattered acne-form pus- 
tules or furunculoid lesions, first appearing upon the face, chest, 
and back, occasionally making their appearance within twenty- 
four hours after the medicine has begun to be taken ; more usually 
it does not appear until after it has been continued from three to 
seven days. Occasionally, according to Echeverria,|| there ap- 
pears a brownish discoloration, conspicuous on the forehead or 
neck ; also diffuse elevations of the skin. Papular lesions may 
appear about the elbows, on the backs of the hands, and on the 
knees and legs. Echeverria, moreover, states that he has seen pain- 
ful subcutaneous suppuration, and in one case ulceration over the 
posterior surface of the forearm. Neumann^ has observed lesions 
like " molluscoid acne," coming on in successive outbreaks; also a 
carbuncular form of disease, with considerable loss of substance 
in the centre. Dr. Cholmeley ** describes a case of what he calls 
"confluent acne," due to the bromide, which resembled in some 
respects that of Neumann, but was more severe. As regards the 
general features of the eruption, this case was closely allied to my 
case due to the iodide cited below. Similar cases have been re- 
ported and figured by Lees ft and Crocker.JJ I have published §§ 
the notes of a case in which the eruption simulated very closely 
the maculo-papular syphiloderm. A peculiarity of this case was 
that the patient had been taking the bromide, in moderate doses, 



* Arch. Gen., lere Ser., t. xviii. p. 92. 

f These de Paris, 1874, p. 35. 

j La France Med., Dec. 1877; Phila. Med. Times, March, 1878. 

| Dublin Jour. Med. Sci., Feb. 1872, p. 198. 

|| Phila. Med. Times, Nov. 30, 1872. 

H" Wien. Med. "Wochenschr., No. 6, 1873 ; Amer. Jour, of Svph. and Derm., 
1873, p. 283. 

** Lond. Clin. Soc. Trans., 1870, vol. iii. p. 38. 

ft Lond. Path. Soc. Trans., 1877, vol. xxviii. p. 247. 

XX Ibid., 1878, vol. xxix. p. 252. 

gg Maculo-papular eruption due to bromide of potassium, Med. and Surg. 
Eeporter, Nov. 30, 1878. 



DERMATJTIS. 349 

almost continuously for three years. The dose being suddenly 
decreased, within five or six days the patient was attacked with an 
erythematous efflorescence about the face, hands, and neck, accom- 
panied by maculo-papules and minute pustules. At the end of three 
days, the medicine being continued, the eruption had extended 
over the entire surface of the body and the limbs. The bromide 
was then stopped. When seen by me two days later, the patient's 
face had a congested violaceous hue; was hot, flushed easily, and 
was the seat of partly confluent maculo-papules, with enlarged 
sebaceous gland ducts, and here and there covered with thin seba- 
ceous crusts. Pea-sized, flat sebaceous crusts were scattered about 
the scalp. The eruption pervaded the entire surface of the body 
and the limbs. About the neck it was of a light violaceous hue, 
while over the body it had a yellowish, tawny color. Slight 
burning sensations were experienced. The eruption passed away 
spontaneously within a fortnight after cessation of the bromide. 
Dr*. Seguin, of New York,* describes a similar case, where the 
disease, situated upon the face and neck, showed papules, pustules, 
and numerous purple, slightly-raised nodules, the size of split peas 
or finger-nails. The same observer states that he has also seen 
several cases of a " rupia-like eruption" in epileptics saturated with 
the bromide of potassium. Yoisin f reports " eczema madidans" 
and severe " pityriasis" of the scalp lasting some months after the 
cessation of the medicine as due to the bromide of potassium. 
Wigglesworth J describes a bullous eruption. Bromine has been 
found in the pustules of the eruption. § The bromide eruptions, 
according to both Voisin || and Veiel,^f are more frequent among 
persons with thick, greasy skins, especially women. Their appear- 
ance may be hindered or mitigated by the simultaneous adminis- 
tration of arsenic, as was originally noted by Echeverria. Gowers ** 
has also written on the value of this remedy as a preventive. As 

* In a letter to the author. 

f Eruptions cutanees par l'usage interne de bromure de potassium, Gaz. 
Med. des Hop., 1868, p. 603. 

$ Proceedings of the American Dermatological Association, Arch, of Derm., 
vol. v. No. 4, Oct. 1, 1879, p. 371. 

§ Guttmann, Virchow's Archiv, 1878, Bd. lxxiv. p. 541. 

|| Loc. cit. 

If Ueber Bromkalium-Acne, Viertelj. fur Derm, und Syph., 1874, p. 25. 

** Lancet, 1878, p. 866. 



350 INFLAMMATIONS. 

a local dressing, where pustules and ulcers exist, a saturated so- 
lution of salicylic acid will be found useful, as recommended by 
Prowse.* According to Ringer, f there appears to be some dif- 
ference in the effects of the different bromides in producing dis- 
ease of the skin, the ammonium salt being the most active in this 
respect, and the sodium salt the least active. 

Cannabis Indica.— Dr. J. Xevins Hyde, J of Chicago, has 
described the case of a gentleman who, having taken a grain of the 
extract of cannabis indica before retiring, awoke the next morning 
covered over nearly the entire body with an eruption of dissemi- 
nated pin-point to split-pea sized vesico-papules and vesicles. The 
facial lesions were rather livid. There was considerable pruritus. 
The disease subsided spontaneously in a few days. I have never 
seen this eruption, nor am I acquainted with any other recorded 
case. 

Chloral. — An erythematous, scarlatina-form, or urticarial 
efflorescence due to the ingestion of chloral hydrate is not very 
rare. Its occurrence seems to be favored by the simultaneous or 
subsequent administration of stimulants. It is of a dusky rose 
color, and is accompanied by itching. According to Martinet,§ its 
favorite seats are the face, neck, chest, the neighborhood of the 
larger articulations, and the hands and feet. Kirn || speaks of 
swelling and heat of the affected parts, with fever and tenderness 
of the skin, lasting many hours. Sometimes the lesions are pap- 
ular upon the extremities. In some cases, according to Kirn, a 
swollen condition of the whole body is noticed; in others, glan- 
dular engorgements. Occasionally, if the medicine be persisted 
in, vesicles and petechia?, with ulceration or sloughing, and even 
death, with symptoms of purpura hemorrhagica, may supervene.^ 

* Brit. Med. Jour., 1880, vol. ii. p. 127. 

f Practitioner, vol. viii., March, 1872. 

% New York Med Eecord, May 11, 1878. 

I These de Paris, 1879. 

|| Practitioner, vol. x. p. 362. 

\ In a case occurring under Kirn's personal observation, where chloral in 
large doses (40 to 75 grs. every evening or twice daily) was persisted in for a 
month or more, papules first appeared upon the face, and became confluent. 
The patient's temperature rose on the twentieth day to 106° F., followed by 
cedema of the face; later, "moist impetiginous and scaly eczema-form erup- 
tions" occurred, succeeded by general desquamation lasting seve-ral weeks, 



DEEMATITIS. 351 

Crichton Brown* also reports a case in which purpuric lesions 
resulted from the use of this medicine. 

Copaiba. — The copaiba rash often follows immediately upon 
the ingestion of the medicine, in the form of a characteristic bright 
cherry-red maculo-papular or papular efflorescence, resembling 
both urticaria and erythema multiforme. It shows itself by prefer- 
ence upon the hands, arms, feet, knees, and abdomen, but some- 
times it appears suddenly, and may invade the entire surface. It 
usually lasts a few days only. Itching is generally present, some- 
times to an intolerable degree. Gubler states that he has seen 
miliary and scarlatina-form eruptions produced by copaiba. f 

Cubebs. — Disease of the skin due to the ingestion of cnbebs is 
rare, and only follows the use of considerable doses, and especially 
in young subjects. In a case noted by Berenguier,J cubebs had 
been given for ten days, when a rash broke out resembling " pap- 
ular roseola," showing a bright-red diffuse coloration of the skin, 
with numerous millet-seed papules coalescing here and there into 
finger-nail sized patches. It was confluent over the face, arms, 
and trunk, but was less abundant over the lower limbs. There 
was no fever, invasion of the throat, or pruritus. It disappeared 
with furfuraceous desquamation a few days after the medicine 
was stopped. 

Digitalis. — According to Behrend,§ Traube in two cases ob- 
served a scarlatina-form eruption and a papular erythema after 
the ingestion of digitalis. 

Iodine, Iodides. — Iodide of potassium may give rise to ery- 
thematous, papular, vesicular, pustular, bullous, and purpuric 
lesions. The erythematous efflorescence, which, compared with 
some of the other forms, is not very uncommon, occurs usually 
upon the forearms in discrete or confluent patches, and also upon 
the face and neck. If the administration of the iodide is persisted 



during which time whole sheaths of epidermis were cast off from all parts of 
the body, and the hair and nails were shed. Finally, a series of large ab- 
scesses formed over the shoulders and in the axillae, and the patient succumbed 
with the symptoms of chronic blood-poisoning. 

* Lancet, April, 1871, pp. 440, 473. 

f Berenguier, loc. cit. 

% Loc. cit. 

| Die Hautkrankheiten, p. 152. Braunschweig, 1879. 



352 INFLAMMATIONS. 

in, this may go on to the papular form, which is rarer. The ve- 
sicular or eczema-form variety has been described as occurring in 
patients long under treatment. By some writers it has been said 
to be most common on the scalp and scrotum. Others describe its 
occurrence on the chest or limbs, and as accompanied by severe 
itching and desquamation. Mercier, quoted by Bumstead and 
Taylor,* describes a case where moderate doses of the iodide brought 
out on two occasions in the same person an eruption like eczema 
rubrum over the whole body, accompanied by fever, with some 
dyspnoea, and so copious an exudation of fluid that the bed on 
which the patient lay was completely wet through. 

The pustular eruption bears a close resemblance to that pro- 
duced by bromide of potassium. Ordinarily it is acne-form in 
appearance, and commonly occurs upon the face, shoulders, back, 
chest, and arms. Sometimes the pustules are followed by indura- 
tions, which may persist. I recently described, under the title of 
" circumscribed phlegmonous dermatitis due to iodide of potas- 
sium,"! a singular case, where, after taking the iodide of potassium 
in moderate doses for some weeks, a slightly inflammatory annular 
patch appeared on the forehead of the patient half an inch in 
diameter, consisting of a number of pin-head sized vesico-pustular 
lesions, looking like an irritated patch of ringworm. This ex- 
tended rapidly, and several similar lesions appeared elsewhere 
upon the face. At the end of a fortnight the original lesion was 
nearly two inches in diameter, consisting of a circumscribed and 
denned, irregularly rounded, elevated, firm, inflammatory, viola- 
ceous patch. Its centre was depressed and crusted, the inflamma- 
tion here having subsided. Scattered over the patch, especially 
about the periphery, were sebaceous pustular lesions, evincing no 
disposition to rupture. When pricked or cut into, the yellowish 
pustular points bled, but did not exude their contents. This case 
resembled very closely the similar eruption described by Cholmeley 
as due to bromide of potassium. AdamkiewiczJ has found iodine 
in the pustules of the iodide eruption. 

The bullous eruption due to iodide of potassium was first de- 



* Venereal Diseases, 4th ed., ]STew York, 1879, p. 815. 
f Med. and Surg. Eeporter, Dec. 13, 1879, p. 516. 
X Charite Annalen, 1878, vol. iii. p. 381. 



DERMATITIS. 353 

scribed by O'Reilly ;* cases have since been reported by Bum- 
stead^ Tilbury Fox,! R. W. Taylor,§ J. Nevins Hyde,|| myself,! 
and others. Dr. Hyde's paper contains an analysis and summary 
of the symptoms presented by this eruption in fourteen recorded 
cases, from which it appears that it occurs most frequently about 
the head, neck, and upper extremities, less frequently upon the 
lower limbs, and rarely upon the trunk. In one instance it 
occurred within the mouth. The eruption begins as pin-point 
sized vesicles or as shot-like papules, at the apices of which vesic- 
ulation appears, the vesicles being of a pale, yellowish-white color. 
In some cases the disease does not go beyond this point, but if the 
iodide be given in large doses or continued the blebs become dark 
red or purplish. In these cases the fluid, at first clear serum, 
becomes puriform and sanguinolent. In a few cases blood only 
was found in the blebs at an early age. When the iodide is 
discontinued the lesions usually disappear within a few days or a 
week. 

Purpura induced by iodide of potassium is among the rarer 
forms of disease caused by this medicine. It has been ably de- 
scribed by Fournier.** It commonly appears soon after the begin- 
ning of a course of the medicine, and is most apt to occur upon the 
legs, less frequently upon the neck, face, and other parts of the 
body. Fournier describes a miliary form of which he has met 
fifteen cases, all but one having been confined to the legs. Some- 
times the eruption occurs in larger patches, and it may even take 
on the form of purpura hemorrhagica and assume a grave char- 
acter. Mackenzie If reports the case of an infant who suffered 
from fatal hemorrhagic purpura following the administration of 
two and a half grains of the iodide of potassium. Duifey|| has 
also written on iodic purpura. 



* New York Med. Gaz., Jan. 1854. 
f Amer. Jour, of the Med. Sci., July, 1871, p. 99. 
X Clin. Soc. Trans., vol. xi., 1877. 
\ Arch, of Derm., April, 1877, p. 227. 
|| Ibid., October, 1879, p. 333. 
\ Med. and Surg. Eeporter, Aug. 4, 1877, p. 89. 
** Eev. Mens, de Med. et de Chir., Sept. 1877. 
ff Med. Times and Gaz., Feb. and May, 1879, pp. 280 and 507. 
X% Dublin Jour, of Med. Sci., April, 1880. 
23 



354 INFLAMMATIONS. 

Mercury. — In connection with the subject of " mercurialism," 
cases of eruption due to mercury were formerly not infrequently 
reported, but of late years a certain amount of scepticism has 
prevailed as to the power of mercury, internally administered, to 
excite eruptions. Hebra* declares very positively that diseased 
conditions of the general cutaneous surface are never excited by 
the internal administration of any of the preparations of mer- 
cury; and my own experience would favor the same conclusion. 
But recently a number of undoubted cases have been recorded 
by Founder and Hallopeau,f Engelmann,J and others, in which 
a partial or entire erythematous efflorescence has been aroused 
by the ingestion of small doses of mercury. The skin became 
smooth, shining, dry, and itchy, and a diffuse deep-red eruption, 
with swelling, resembling erysipelas, began in the face. Other 
parts of the body were gradually invaded. 

Opium, Morphia. — The efflorescence caused by opium and its 
preparations is usually of an erythematous character, often closely 
resembling that of scarlet fever. Behrend § has recorded the case 
of a man who, after taking one-fourth of a grain of opium every 
hour (amounting to two grains and a half in the course of the 
dav). was attacked by violent itching, with a punctiform scarlet 
rash, chiefly over the chest, inner and flexor -ides of the forearms 
and wrists, and inner and flexor sides of the lower limbs and ankles. 
It lasted between one ami two weeks, and desquamated in large 
flakes, especially over the backs and palms of the hands and over 
the soles of the feet. Seguin|| give- a case of dermatitis produced 
by three preparations of opium in the same subject. Berenguier^f 
alludes to profuse sweat-, and sometimes sudamina, as following 
its administration. The milder forms of eruption disappear in a 
few hours, and leave no desquamation, while the more marked 
forms last longer, and are sometimes accompanied by complete 
desquamation of the affected parts. Apolant** gave a patient a 



* Hebra u. Kaposi, Lehrbuch der Hautkrankheiten, 2 Aufl., 1872, Bd. 
p. 452, Erlangen. 

f Du Mercure, Paris, 1878, p. 110. (Quoted from Behrend.) 

% Berlin. Klin. Wochenschr., Oct. 27, 1879. 

I Ibid., Oct. 20, 1879, p. 626. 

|| Arch, of Med., No. 1, Feb. 1, 1879. tf Loc. cit. 

** Berlin. Klin. Wochenschr., No. 25, 1878, p. 361. 



DERMATITIS. 355 

few drops of a solution containing a grain and a half of morphia 
in two and a half drachms of water. Within a short time a 
marked efflorescence appeared, with heat and itching; the face 
was ©edematous, and wheals occurred on the buttocks and hands. 
Lamellar desquamation followed in five days. 

Phosphoric Acid. — Hasse* records the occurrence of a bullous 
disease, which he regarded as pemphigus, in the case of a young 
girl who had been taking phosphoric acid, which disappeared when 
the medicine was suspended, but returned when it was given once 
more. 

Quinine. — The efflorescence due to this drug is usually ery- 
thematous, and may be brought out by even very small doses. It 
is ordinarily preceded by a chill, nausea, vomiting, headache, and 
fever. A little later, in most cases, erythema appears, accompanied 
by oedema, injection of the conjunctivae, and redness and dryness 
of the pharynx and nasal passages. The cutaneous manifestation 
shows itself first upon the face and neck, and spreads over the 
body in patches of various size, which may become confluent, the 
eruption then becoming general. It is accompanied by a decided 
burning and itching. In some cases the eruption resembles scar- 
latina very closely. Desquamation, sometimes lasting weeks, may 
follow. In other cases the eruption resembles measles, f Occa- 
sionally it assumes the papular form, resembling erythema multi- 
forme papillosum,! and urticarial Kobner|| reports a case where 
quinine always produced an erysipelas of the scrotum, and Morrow^f 
refers to Panas, who asserts that large doses have given rise to a 
bullous eruption. The efflorescence is said to occur more fre- 
quently among women. Bergeron and Proust** have also noted 
a disease occurring among workmen in quinine-factories. In these 
cases the lesions are said to have been eczema-form in character, 
and were brought on by the local action of the drug (or by the 
materials used in its manufacture) upon the skin rather than by 



* Zeitschr. fur Natur- u. Heilk., Dresden, 1820, i., 3 Stuck, p. 362. 
f Kobner, Berlin. Klin. Wochenschr., May 28, 1877. 
% Heusinger, Berlin. Klin. Wochenschr., June 18, 1877. 
I Dumas, Jour, de Therap., 1876, p. 288 ; also Morrow, New York Med. 
Jour., March, 1880, with a biography. 

|| Loc. cit. \ Loc. cit. 

** Annales d'Hygiene, July, 1876. 



356 ' INFLAMMATIONS. 

the absorption of the quinia into the system. A purpuric form 
of eruption has also been noted, five cases of which, according to 
Morrow, have been reported. In one of these,* two grain doses 
continued for four days were sufficient to bring out the disease, 
together with hemorrhage from the gums. 

Salicylic Acid. — The cutaneous lesions attributable to sali- 
cylic acid are of several different kinds. Heinleinf observed a 
case in which salicylate of sodium was given in seven grain doses 
hourly for ten days, and then increased to sixty grain doses. Soon 
after the first sixty grain dose had been taken, intense itching and 
tingling of the skin set in, followed by fever and a diffuse erythe- 
matous efflorescence on the left side of the face and chest and on 
the lower extremities, together with some oedema of the eyelids, 
upper lip, and lower limbs. The medicine being decreased, the 
eruption disappeared, but on taking a sixty grain dose of the sali- 
cylate again, an urticarial eruption showed itself within half an 
hour on the greater part of the body, with oedema of the eyelids 
and arms. This moderated in a few hours and disappeared the 
next day. Small doses did not seem to excite the eruption. Freu- 
denbergf describes a case where, after taking salicylic acid, the 
patient's back was covered with ecchymotic patches, which ex- 
tended to the sides and chest. The acid was discontinued, and 
by the sixth day the eruption had disappeared. The patient was 
anaemic. Wheeler § observed vesicles and pustules on the hands 
and feet, with much sweating, which disappeared upon stopping 
the administration of the medicine. 

Santonine. — Sievekiug || reports a case where three grains of 
santonine were given to a child, who soon after showed an urtica- 
rial efflorescence over the face and body. The face was swollen, 
and there was oedema of the eyelids. The child was put in a bath, 
and the rash and oedema disappeared within an hour or so. 

Stramonium. — DeschampsTf states that he has observed an 
erythematous eruption after the use of datura stramonium. 

* Gauchet, Bull. Gen. de Therap., t. lxxix. p. 373. 

f Rundschau, 1878, xix., 10 Heft. 

X Berl. Klin. Wochenschr., No. 42, 1878. 

I Bost. Med. and Surg. Jour., Oct. 17, 1878. 

|| Brit. Med. Jour., Feb. 18, 1871. 

\ Gaz. des H6p., 1878, No. 124. 



DEEMATITIS. 357 

Strychnia. — Skinner* reports a case where one-quarter of a 
grain of quinine, given three times a clay, having given rise, even 
after the second dose, to a scarlatina-form rash, one twenty-fourth 
of a grain of strychnia was substituted, but with a precisely simi- 
lar effect. 

Turpentine. — The eruption most frequently observed as a 
result of the ingestion of turpentine in large doses is erythematous 
in character, occurring usually over the face and upper part of the 
trunk, in some instances accompanied by a profuse rash of minute 
papules. It may be diffused. It is apt to be accompanied by 
violent itching. Occasionally, according to Berenguier,f vesicular 
lesions are produced, closely resembling acute vesicular eczema. 

According to Behrend,J who has published an interesting paper 
on the subject of these dermati tides, an examination of the symp- 
toms described as aroused by drugs shows that they may be divided 
into two classes: 1. The pustular, embracing the iodine and bro- 
mine eruptions ; 2. The various eruptions occasioned by other 
medicines. The first class is usually characterized by the late 
appearance of the disease, it being due, it would seem, to a satura- 
tion, or at least a thorough impregnation, of the organism by the 
drug. The rash in one form or another occurs in all who take 
the drug in sufficient quantity, becoming more marked as the 
quantity of the drug is increased, and fading away with its dimi- 
nution. There are, of course, differences in the lesions due to 
individual idiosyncrasy. Persons with thick oily skins are more 
prone to this class of eruption. The fact that iodine and bromine 
have been detected in the pustules goes to show that they are pro- 
duced by irritation during the excretion of these drugs. Against 
this view, however, must be mentioned the report of a microscopic 
examination of the lesions in Cholmeley's case, made by Dyce 
Duckworth, whose investigations led to the conclusion that the 
pustules were not of the nature of acne, but were due to superficial 
localized dermatitis. § 



* Brit. Med. Jour., Jan. 29, 1870. 

f Loc. cit. 

% Berl. Klin. Wochenschr., 1879, Nos. 42 and 43. 

I Trans, of Lond. Path. Soc, 1879, vol. xxx. p. 476. 



358 



INFLAMMATIONS. 



The second class take on the exanthematic form, often extend- 
ing over large portions of the surface. They are usually acute, 
in many cases occurring after an initial chill, and are generally 
accompanied in their course with high temperature and gastric 
disturbance; in some cases these symptoms are wanting. They 
usually appear immediately or as soon as the medicine is absorbed 
and reaches the circulation. There are, however, exceptions to this 
rule, as in the case of the arsenic eruptions, where the drug is 
sometimes taken for some time before producing any effect upon 
the skin, even in individuals who are subject to such influence. 



CLASS IV. 
HEMORRHAGES—HEMORRHAGES. 

Hemorrhages into the skin assume certain external appear- 
ances which are designated, according to their form and size, as 
petechia?, vibices, ecchymoses, and ecchymomata. These may be 
defined as follows : 

Petechia? are roundish, ovalish, or irregular in form, and vary 
in size from a pin-point to a finger-nail. Vibices are long, nar- 
row, streak-like lesions, varying in size from a few lines to an 
inch or more. Ecchymoses are large, variously sized, roundish, 
or irregularly-shaped, non-elevated, superficial patches. Ecchy- 
momata consist of extensive extravasations, which appear in the 
form of variously sized and shaped, deep-seated, flat or raised 
patches or tumors. 

Cutaneous hemorrhages may occur either through diapedesis or 
as an extravasation. They may be the result of external injury, 
in which case they are termed idiopathic, or they may take place 
as a symptom of some internal disease, when they are designated 
symptomatic. 

Idiopathic Hemorrhage. — To this category belong all those 
conditions which are produced by wounds, contusions, and other 
forms of direct violence to the integument, and by mechanical 
vascular disturbances, as in varicosities. In these cases the ves- 
sels are ruptured and the blood extravasated in greater or less 
quantity into not only the skin but also the deeper structures. 
Under this head also are to be placed the minute, circumscribed 
hemorrhages produced by the bites of various insects, among 
which the pediculus, flea, and bed-bug may be mentioned as 
giving rise to the most mischief. 

Symptomatic Hemorrhage. — The hemorrhage here takes 
place spontaneously, showing itself as apparently the only disease, 



360 HEMORRHAGES. 

as, for example, in purpura simplex; or, as a symptom in the 
course of certain severe constitutional diseases, as in variola and 
typhus fever; or, finally, as a secondary symptom in other diseases 
of the skin, as in pemphigus, ecthyma, and erythema nodosum. 

The general characters of cutaneous hemorrhage have been 
already stated in the chapter upon the pathology of the skin. 

PURPURA. 

Sy?i., Hemorrhoea Petechials ; Germ., Purpura; Blutfleckenkrankheit ; 
Fr., Purpura. 

Purpura consists in the development of variously sized 
and shaped, non-elevated or raised, smooth, reddish, hemor- 
rhagic patches, characterized by remaining under pressure. 

Symptoms. — Three varieties are met with. These differ in the 
premonitory symptoms which precede the cutaneous manifestation, 
in the amount of constitutional disturbance attending the disease, 
in the extent of the hemorrhage, and in the etiology. The exter- 
nal forms of the lesions, their size, shape, number, and color, are 
likewise found to be different. 

Purpura Simplex. — This variety rarely exhibits symptoms of 
systemic disturbance. Frequently the spots are the only manifesta- 
tions of disease. At times they give rise to so little inconvenience 
that their presence may for a time escape detection on the part 
of the patient. Occasionally, however, the patient complains of 
feeling unwell, of loss of appetite, and of fatigue on exertion, for 
some days before the cutaneous lesions appear. They generally 
make their appearance suddenly, often in the course of a night, at 
other times more gradually, in the form of bright-reddish, claret- 
colored, or purplish, sharply circumscribed, roundish, ovalish, or 
irregularly-shaped, hemorrhagic spots.* They vary in size from 
a pin-point to a pea or bean. They usually occur in numbers and 
symmetrically, their common seat being upon the lower extremities, 
the flexor surface of the thigh being the locality most frequently at- 
tacked ;f other regions, however, are also involved. They exhibit 
a tendency to appear in a scattered manner, invading a consider- 

* Rarely, they may assume a circinate or annular form, as in a case reported 
by me in Med. and Surg. Reporter, Aug. 3, 1878. 
| See my Atlas of Skin Diseases, Plate K. 



PURPURA. 361 

able amount of surface. They are, as a rule, unaccompanied 
by subjective symptoms. Sometimes, however, slight itching or 
pain is present. Soreness is more frequently complained of. At 
times, where there is a disposition in the skin to the ready devel- 
opment of wheals, these lesions may show themselves in con- 
nection with the hemorrhage, constituting purpura urticans, 
in which case the itching may be marked. In many cases the 
nervous system is unquestionably at fault, constituting so-called 
neurotic purpura. Mitchell* and Tyrrell f have both called at- 
tention to this cause of the disease. In all the cases reported by 
the last named observer the subjects had been exposed to marsh- 
miasm in malarial districts, which he regarded as the primary 
cause. Blebs have also been noted in association with purpura, 
as in the case of recurrent cutaneous hemorrhage with urticarial 
and bullous efflorescence reported by White.J It happens occa- 
sionally that the disease is produced by the internal administra- 
tion of medicines, cases of which have been reported by Fournier,§ 
Abbe, 1 1 T. C. Fox,^f and Mackenzie,** from iodide of potas- 
sium; Oichton Brown,ff from chloral; Jeudi de Grissac,JJ 
from quinia; and Freudenberg,§§ from salicylic acid. 

The disease is more frequently observed in the old than in the 
young. Its duration may vary from a fortnight to several months. 
The cutaneous lesions are apt to relapse, in the form of crops, 
throughout the course of the disease. The causes are sometimes 
obscure ; it occurs in those who are apparently well nourished, 
but it is much oftener encountered in debilitated subjects. The 
lesions when small are liable to be confounded with flea-bites ; the 
central hemorrhagic point in the latter, however, surrounded by 
more or less congestion, will usually be sufficient to differentiate 
them. 

* Amer. Jour, of Med. Sci., July, 1869, p, 116. 

f Pacific Med. and Surg. Jour., June, 1876. 

% Bost. Med. and Surg. Jour., Oct. 10, 1878. 

§ Kev. Mens., Sept. 1877. 

|| Arch, of Derm., April, 1878. 

% Brit. Med. Jour., May 31, 1879. 

** Med. Times and Gaz., vol. i., 1879. 

ff Lancet, vol. i., 1871. 

XX Des eruptions quiniques. These de Paris, 1876. 

H Berl. Klin. Wochenschr., No. 42, 1878. 



362 HEMORRHAGES. 

Purpura Rheum atica, — Peliosis Rheumatica. — This va- 
riety is ushered in with more or less fever, lassitude, loss of appetite, 
and marked depression of spirits, together with severe rheumatic 
pains throughout the body, more particularly about the joints of 
the lower extremities. In the course of a few days or a week, the 
eruption suddenly makes its appearance over a part or the whole 
of the body, the lesions being most distinct over the arms, thighs, 
and legs. They consist of more or less well denned hemorrhagic 
spots, pinkish, reddish, or purplish in color, varying in size from 
a split pea to a finger-nail. They are either slightly raised or on 
a level with the surrounding skin, and are unattended by sub- 
jective symptoms ; a general soreness, however, is apt to be felt 
over the whole integument. The color of the eruption undergoes 
changes from time to time, passing into yellowish and greenish 
hues, until finally, with the absorption of the blood, it gradually 
fades away. 

The disease may last a few weeks or months, in which case 
new hemorrhagic spots appear in the form of relapses. The con- 
stitutional symptoms, consisting of depression, loss of strength, 
weariness, and allied feelings, often remain throughout the attack, 
and are generally marked. The rheumatic pains which precede 
the hemorrhage are apt to abate materially upon the appearance 
of the eruption. The disease is encountered in both men and 
women, more often in the latter, and ordinarily occurs during 
middle life. In certain cases it is associated with erythema mul- 
tiforme. As a rule, no causes can be assigned for the disease.* 
It is regarded by some observers as an affection of the vaso-motor 
system. In my experience the disease is uncommon. 

The diagnosis is at times difficult, especially in those cases in 
which the lesions are imperfectly developed; the eruption may 
under these circumstances bear a resemblance to the macular 
syphiloderm.f Here the premonitory symptoms, together with 
the absence of itching, also point towards syphilis. Upon close 
inspection, however, the hemorrhagic character of the lesion may 
be detected. If seen before the appearance of the eruption, the 
disease may be mistaken for rheumatism. 

* For a report of cases of this form of purpura, see an article by Dr. Kinnicutt, 
of New York, in Arch, of Derm., vol. i. p. 193. 

f See a paper by me, in Phila. Med. Times, 1873, vol. iii. p. 545. 



PURPURA. - 363 

Purpura Hemorrhagica,— Land Scurvy, — Morbus Ma- 
culosus Werlhoffii. — This form usually begins with premoni- 
tory symptoms of a decided character, consisting of debility, loss 
of appetite, languor, headache, and feelings of general distress. 
The spots first make their appearance upon the limbs, extending 
thence rapidly to the trunk and upper extremities. Their advent 
is generally sudden. They are usually in great numbers. In 
size they vary from a small coin to the palm of the hand ; not 
infrequently two or more coalesce and form irregularly-shaped 
patches. A variety of sizes and shapes are usually encountered. 
Simultaneously with the cutaneous lesions, or later, hemorrhage 
from other portions of the body, particularly the mouth, gums, 
nostrils, bowels, and bladder,- may take place. This may be either 
slight or violent in its character, large quantities of blood not 
infrequently being discharged. The constitutional symptoms of 
depression and debility are apt to continue as long as there is 
tendency to hemorrhage. 

According to Rigal and Cornil,* the disease is the result of 
debility caused by nervous exhaustion. The hemorrhage is due 
to disturbance of vascular innervation, dependent either upon 
irritation of the sympathetic or upon diminished action of the 
vaso-motor centres. 

The course and duration of the disease are variable; it may 
continue for days and weeks, in the form of relapses, or it may 
terminate completely within a week or a fortnight. The hemor- 
rhage may cease suddenly or by degrees. It is encountered in 
both children and adults, although more frequent in the latter. 
It occurs in the strong and properly cared-for as well as in the 
weakly and improperly fed. It is a serious disease, and may end 
fatally. 

Purpura hemorrhagica differs from scurvy, the disorder to which 
it bears most resemblance, in important particulars. Purpura is 
commonly observed in those who have not been subject to the 
peculiar influences which give rise to scurvy, namely, bad hygiene, 
improper diet, and the want of vegetable food in particular. In 
purpura the premonitory symptoms are not always of a distinctive 
character, and may at times be altogether absent ; in scurvy they 

-Abstract from L'TJnion Med. in Phila. Med. Times, March 12, 1881. 



364 HEMORRHAGES. 

are invariably present, and constitute a pathognomonic group, 
consisting of absolute weakness and general debility, impaired cir- 
culation, tumefaction of the gums with bleeding, and looseness of 
the teeth. Purpura is apt to announce its presence suddenly; 
scurvy always slowly. 

Pathology. — The blood is in the majority of cases suddenly 
extravasated into the cutaneous tissues, and finds its way into the 
various layers and structures; at one time having its chief seat in 
the tissue of the corium itself or subcutaneous connective tissue, at 
another time about the glands and follicles. According to the 
amount of blood extravasated and the permeability of the tissues, 
will the spots be small or large, circumscribed or diffused, roundish 
or irregular in shape, and otherwise peculiar. The process, as a 
rule, is unattended by inflammation or by subjective symptoms; 
frequently it takes place unawares to the patient. It is neurotic 
in nature certainly in many cases. Sometimes complications arise, 
other forms of disease accompanying the hemorrhagic lesions, as 
in the case reported by White, referred to. The blood once out 
of the vessels acts as a foreign body in whatever part of the skin 
it may chance to be, and can be removed only by resorption. 
This process is usually a slow and gradual one, the fluid, more 
particularly in its coloring matter, undergoing various changes, as 
seen in the variety of tints, as yellow, green, blue, and purple, 
which the spots from time to time assume in the course of their 
decline. Sooner or later, in the course of weeks or months, the 
tissues return to their normal state. 

Treatment. — The plan of treatment in purpura must be adapted 
to the requirements of the case. Inasmuch as the causes producing 
the disease often appear to be different in their nature, so will the 
general treatment call for more or less modification. The diet 
and hygiene should both receive attention. If the hemorrhage 
be extensive, rest in the horizontal position is of the utmost 
importance. 

In purpura simplex, ergot, the preparations of iron, especially 
the tincture of the chloride, quinine, belladonna, and the mineral 
acids, together with frictions and cold baths, are all beneficial. 
Harkin* speaks highly of the value of chlorate of potassium, in 

* Brit. Med. Jour., Oct. 30, 1880. 



PTJEPUEA. 365 

twenty grain doses, where there is a hemorrhagic diathesis. Pur- 
pura rheumatica calls for particular attention to hygiene and diet ; 
fresh air, change of occupation, the best of food, including stimu- 
lants and malt liquors, and regulation of the in^ortant functions 
of the economy, are to be prescribed to suit the demands of the 
case. 

Purpura hemorrhagica, usually an alarming and at times a serious 
or even fatal disorder, calls for prompt treatment. Pest in bed is 
to be enjoined upon the patient. Ergot, quinine, iron, aud the 
mineral acids, as in the other varieties of purpura, are the reme- 
dies found to be of the most value. Cases are reported by Lane,* 
Minich,f and Armaingaud,J in which hypodermic injections of 
ergotine promptly relieved the disease. Oil of turpentine, and 
astringents, as the acetate of lead with opium, may also be men- 
tioned as remedies enjoying reputation. Electricity has been used 
with success after the failure of other remedies, as in a case re- 
ported by Shand.§ The external treatment should consist of ab- 
lutions with astringents in solution, as alum, tannic acid, vinegar, 
and the like. Ice, applied frequently to the parts, is perhaps one 
of the best local remedies. Enemata of ice-water are also useful 
where there is hemorrhage from the bowels. 

Prognosis. — This must vary not only with the variety of the 
disease, but also with the case. In purpura simplex the prognosis 
is always favorable as to ultimate recovery, although restoration 
to health may be slow. The same may be said of purpura rheu- 
matica, although this form is apt to be stubborn, and to prolong 
its course indefinitely by frequent relapses. In purpura hemor- 
rhagica the prognosis should always be extremely guarded, for the 
disease is serious and treacherous; it is impossible to predict what 
course it will pursue. Rigal and Cornil || state that the gravity 
of the disease does not depend on the amount of blood extrava- 
sated. 

ELematideosis. — This disease (known also by the names hsemi- 

* Brit. Med. Jour., Sept. 5, 1874. 

f Phila. Med. Times, May 8, 1875. 

% Le Mouvement Medical, 1878, p. 552. 

I Lancet, July 19, 1879. 

II Loc. cit. 



366 HEMORRHAGES. 

drosis, ephidrosis cruenta, sudor sanguineosa, sudor cruenta, and 
bloody sweat) consists in the appearance at the outlets of the ex- 
cretory ducts of the sweat glands of a reddish fluid containing 
blood. It is usually in small quantity and localized, and oozes 
forth upon the surface of the skin without giving rise to any 
lesion of the epidermis. It is to be considered as a cutaneous 
hemorrhage, which takes place about the sweat glands, emptying 
itself through the sweat ducts. It is a very rare disorder. An 
interesting case is reported by Hart.* MeCall Anderson has also 
reported cases. f Instances of chromidrosis have in some cases 
been designated haematidrosis, and vice versa, but in the disease 
under consideration the fluid poured out contains or consists 
largely of blood, which is not the case in chromidrosis. The 
affection has been observed most frequently in young women with 
faulty menstruation. Occasionally it has been noted to precede 
the establishment of the menstrual function, as in W. T. Mitchell's 
case.J The exciting causes which may produce it arc passion and 
unusual nervous strain. The treatment is that of purpura. 

Under the title of NEUROTIC EXCORIATIONS, Erasmus Wilson § 
has described a number of cases, some of which may be regarded 
as examples of irregular haematidrosis. These cases, met with in 
young women and in adults of both sexes, and dependent on gen- 
eral functional debility, are characterized by variously sized and 
shaped, small or extensive, superficially excoriated patches, pre- 
ceded usually by more or less itching. The primary lesions vary, 
but are usually erythematous, papular, or bullous, accompanied, 
as a rule, with burning, tingling, or itching. From scratching, an 
excoriation, with or without bleeding, results; which may remain 
open or may heal in the course of a variable time. The process 
usually repeats itself, and may become chronic. 

In this connection the cases of so-called BLEEDING stigmata, 
instances of which have from time to time been reported, may be 
briefly referred to. The disease here is without question a form 
of haematidrosis, sometimes preceded by the formation of blebs, 

* Richmond and Louisville Med. Jour., Jan. 1875, p. 98. 
f Journal of Cutaneous Medicine, Oct. 1807 ; also Lectures on Clinical 
Medicine, London, 1ST 7. 

I Ohio Med. Recorder, May, 1881. 

I Lectures on Dermatology, p. 192. London. 1875. 



PURPURA. 367 

and usually associated with hysteria and ecstatic symptoms, as in 
the well-known case of* Louise Lateau, which has been made the 
subject of study by Warlomont* and Lefebvre.f The bleeding 
may occur from one or from many spots, which may vary as to 
size and shape, and from various regions. It may continue a 
short or a long period, usually hours, recurring at irregular inter- 
vals. The quantity of blood discharged is generally small. In 
the case of Louise Lateau, however, where the stigmata were 
numerous, the amount lost at first on each occasion was estimated 
at a quart ; in subsequent hemorrhages it is said to have been 
very much less. A similar example is reported from Bahia,| 
entitled "la stigmatises de Bahia," where, however, the peculiar 
ecstatics of Louise Lateau were absent. 



* Louise Lateau : Eapport Medical. Paris et Bruxelles, 1875. 
f Louise Lateau, de Bois d'Haine ; sa vie, ses ecstases, ses stigmates, 
Louvain, 1873. 

% Le Mouvement Medical, JNo. 1, 1877. 



CLASS -V. 
HYPERTROPHIC— HYPERTROPHIES. 

A number of diseases naturally group themselves into this 
class. They are characterized by an increase of the elements of 
the normal tissues of the skin. The various structures which con- 
stitute the integument are all subject to hypertrophy, the process 
either confining itself to one tissue or attacking several or all of 
the tissues simultaneously. The diseases may have their seat ex- 
clusively in the epidermis, as in chloasma and callosity, or they 
may involve both epidermis and papillary layer, as in ichthyosis 
and wart. In other cases the coriura is the chief seat of the 
process, as, for example, in elephantiasis. The hair and nail may 
also suffer. 

The hypertrophies are, with several exceptions, characterized 
by the absence of inflammatory symptoms. In the majority of 
instances they give rise to no serious inconvenience, and in these 
cases are to be viewed in the light of deformities. Their course is 
slow. They may continue years or a lifetime. They may be con- 
genital or acquired ; the greater number are acquired. Their path- 
ological features have been already referred to in the consideration 
of the general pathology of the skin. 

LENTIGO. 

Syn., Freckle ; Germ., Sommersprosse ; F/\, Lentigo. 

Lentigo consists in a pigment deposit, characterized by 
irregularly-shaped, pin-head or pea sized, yellowish, brown- 
ish, or blackish spots, occurriug for the most part about 
the face and the backs of the hands. 

Symptoms. — The affection varies exceedingly in the degree 
of its development. At times the lesions are few and scattered, 
while in other instances and ordinarily they are present in large 



LENTIGO. 369 

numbers. They are usually small, varying in size from a pin- 
head to a small split pea, and are roundish, irregularly shaped, or 
angular. They are either isolated, in which case they are often 
conspicuous, or they are aggregated and incline to coalesce ; they 
assume no regularity of distribution, but show themselves sym- 
metrically. Their color varies from pale yellow to yellowish- 
brown or black. When profuse, they are apt to give the skin a 
decidedly dirty look. Their common seat is the face, especially 
over the cheeks; they appear also very frequently upon the backs 
of the hands and forearms. Other regions may also be attacked. 
They are unattended by itching or other subjective symptoms. 

Persons of all ages, from childhood to old age, are liable to 
them ; they are not seen, however, in very young children ; rarely 
before the third year. They are common to both sexes. They 
usually manifest, themselves in those of light complexion, and 
indeed are rarely absent in red-haired subjects ; but they are also 
met with in those with dark complexions. Mulattoes often show 
them markedly. Their course is chronic, lasting for years or a 
lifetime. They ordinarily make their appearance in the summer 
season, sometimes quite suddenly, and, continuing through the 
season, fade away, but not completely, with cold weather, to return 
the following season. As the individual advances in years they 
are apt to disappear and remain away permanently. Under the 
title of "melasma lenticulare," or " lenticular nigrse," Wilson* 
gives the case of a young lady whose body was sprinkled over with 
black freckles. They appeared first round the waist, and thence 
spread upwards and downwards to the neck and thighs. Their 
color was a rich brown-black, and they had existed for three 
years. They began as small itchy papules at the apertures of the 
follicles, and when the acute stage was passed the pigment made 
its appearance and became diffused around the aperture of one or 
several follicles to the extent of two and three lines. Freckles, of 
an intense brownish or blackish color, are also met with as one 
of the symptoms in certain rare forms of atrophy of the skin 
complicated with telangiectasis, as in the cases reported by Hebra 
and Kaposi, Taylor, and myself. (See Atrophy of the Skin.) 

Etiology. — It is well known that they are always more marked 



* Lectures on Dermatology, p. 22. London, 1878. 
24 



370 HYPERTROPHIES. 

during the summer, and especially after exposure to the sun ; but 
Hebra has particularly called attention to the fact that they some- 
times appear upon parts of the body which are rarely, if ever, 
exposed to the light or sun, as, for example, the back, buttocks, 
and penis,* when they are known as " cold freckles." It may be 
stated, then, that other causes, as in the case of the rare form of 
atrophy of the skin referred to, are to be regarded as giving rise 
to the affection. The sun in the majority of cases, however, may 
be considered as the exciting cause. 

Pathology. — In anatomical structure the freckle is found to 
consist of a circumscribed, increased amount of normal pigment. 
It differs from chloasma only in the peculiar form and size of the 
lesion. 

Treatment. — The remedies which are used for removing these 
blemishes are the same as those employed in the treatment of the 
more serious disfigurement chloasma, to be mentioned presently. 

CHLOASMA. 

Chloasma is a pigmentary affection, consisting of variously 
sized and shaped. more or less defined, smooth patches, or 
of a discoloration, yellowish, brownish, or blackish in color. 

Symptoms. — The surface of the skin is unaltered in structure, 
the affection being one simply of coloration. The patches may be 
of any size, from a coin to the hand or larger; they may likewise 
be of any shape, but are frequently roundish or irregular in out- 
line, and usually possess a tolerably sharp line of demarcation. 
They have a yellowish or brownish, muddy, dirty color, and may 
be even blackish (melasma, MELANODERMA"}"). Chloasma may 
also show itself over the whole surface in the form of a universal 
discoloration, variable as to color; this is observed at times in the 
course of certain diseases of internal organs. 

The chloasmata may be divided into those which are idiopathic 
and those which are symptomatic. Under the first head are in- 
cluded all those forms of pigmentation acquired through external 

* I have had the opportunity of seeing several eases in which they occurred 
upon these regions. See also Hebra's Atlas d. Hautkrankh., Lief. VIII., Tafel G. 

f A description of the various forms of melanoderma may be found in an 
article by Dr. J. C. "White, in Bost. Med. and Surg. Jour., vol. i., 1878. 



CHLOASMA. 371 

agencies, among which may be mentioned the condition resulting 
from constant and long-continued scratching, which is practised 
in the course of certain diseases of an itching character, as in 
eczema and pediculosis. Chemicals and various medicinal sub- 
stances, as, for example, sinapisms and blisters, also produce more 
or less pigmentary deposit. Heat, especially in the form of the 
rays of the sun, is a well-known cause of discoloration. When 
the action of these agents is kept up, the result is apt to be lasting. 

Belonging to the symptomatic group, we find the disorder 
known as chloasma uterinum, as well as those discolorations 
which occur in connection with certain general diseases, as, for 
example, tuberculosis, cancer, and malaria; in these latter cases 
the pigmentation is, as a rule, diffused. The pigmentation of the 
skin occurring in Addison's disease is perhaps the most striking 
example of this form of chloasma. Here, in typical cases, the 
coloration is brownish with an olive-greenish or bronze tint, and 
is general, although, as a rule, especially pronounced upon regions 
having a disposition to normal increase of pigment, as the face, 
backs of the hands, axillae, areolae of the nipples, and genital 
organs ; the hair also may become darkened. It may also occur 
with or follow other pigmentary changes, as of the hair. Gaskoin* 
reports a case, occurring in a woman aged forty-five, where the 
patch, situated on the cheek, near the nose, was intensely dark. 
It had existed nine years. The color of her hair had fifteen 
years previously changed from carroty-red to black. More or 
less chloasma is also found in senile atrophy, and in the course 
of other diseases of the skin, as scleroderma, morphcea, lepra, 
syphilis, and pellagra. 

Chloasma Uterinum. — It occurs in its mildest expression 
about the eyelids, especially at the menstrual period, causing a 
duskiness or swarthiness of the complexion, which may last a few 
days or be permanent. It shows itself in all degrees of severity, 
and is especially pronounced in brunettes. The condition is allied 
in its general pathology to certain forms of disease usually classi- 
fied with chromidrosis. As usually encountered, the disease con- 
sists in the presence of one or several patches of pigment deposit, 
appearing generally about the forehead, but also upon other parts 

* Brit. Med. Jour., April 19, 1879. 



372 HYPERTROPHIES. 

of the face, and upon the trunk about the nipples and abdomen. 
The condition is oftenest observed in the form of a broken or con- 
tinuous patch involving the forehead, usually beginning below the 
line of the hair and terminating above the eyebrows, and extending 
transversely from temple to temple. The patch may be distinctly 
defined or may fade imperceptibly into the normally-colored skin. 
Occasionally the whole face is occupied by a diffused discoloration, 
resembling a mask. The color varies from dirty yellow to brown. 
As a rule, there is no desquamation, the surface being smooth. 
< Occasionally it is associated with oily seborrhcea. It is seen 
most frequently between the ages of twenty-five and fifty, and is 
caused, in the majority of cases, by changes, physiological and 
pathological, which take place in connection with the uterus. 
Pregnancy is the commonest cause. McLane* records an extraor- 
dinary case occurring in an anajmic woman at the eighth month 
of pregnancy. The pigmentation exhibited itself in patches 
varying in size from one to six inches square, the largest being 
on the neck, back, and thighs, in which localities the skin was 
very nearly the color of that of a negress. There was no un- 
usual pigmentation about the nipples, or along the median line 
of the abdomen. The pigmentation may extend over the whole 
surface and resemble Addison's disease, as in a case noted by 
Murphy ;f also in an instance recorded by Wilson,! where the 
pigmentation spread from the breasts a- a centre until it covered 
nearly the whole of the anterior aspect of the trunk ; a year after 
delivery it had entirely disappeared. Various other disturbances 
of the uterine function may also occasion it. It appears in 
single as well as in married women ; it is, however, of compara- 
tive rarity in the single, and in these cases is generally associated 
with either dysmenorrhcea, chlorosis, anaemia, or hysteria. In 
single women it is usually encountered between the ages of thirty 
and fifty. It seldom shows itself after the climacteric period in 
either the single or the married. 

Etiology. — The causes which give rise to chloasma are numer- 
ous, and are very different in their nature; they are to be consid- 
ered in connection with the respective varieties of the disorder, 



* Amer. Jour. Obst., Oct. 1878. f Obst. Gaz., Jan. 1880. 

1 Lectures on Derrnatolosrv, London, 1878. 



chloasma. 373 

which are named from an etiological stand-point. The causes 
of the more important varieties have been already referred to. 
While much more common in women, the affection is also met 
with in men. Shock to the nervous system, neurotic disturbance, 
irritation of the various internal organs, are all well-known causes. 
The relation of pigmentary deposits in the skin to ansemia, 
as Erasmus Wilson has pointed out, is in some cases intimate. 
The discolorations of syphilis, as the pigmentary syphiloderm, 
occurring in anaemic subjects, may thus be accounted for. 

Pathology. — The affection has its seat in the mucous layer of the 
epidermis. It consists in an increased deposit of normal pigment. 
The process is, without doubt, under the control of the nervous 
system, as is the case with certain other varieties of pigmentation. 
The pigment may be absorbed in time, the part again assuming 
its natural color. 

Diagnosis. — It is liable to be confounded with tinea versicolor, 
on account of the similarity in the color of the patches ; beyond 
this point, however, the two diseases have nothing in common. 
The patches of tinea versicolor are usually more numerous than 
those of chloasma, and always occupy the trunk, a region seldom 
invaded by chloasma except in the form of a general coloration. 
The face is the commonest seat of chloasma, a region practically 
exempt in tinea versicolor. The characters of the patches are 
different, and if carefully examined they cannot be mistaken for 
each other. Those of chloasma are usually smooth, presenting 
no alteration in the texture of the horny layer of the epidermis; 
those of tinea versicolor are more or less furfuraceous, which con- 
dition can be readily demonstrated by gently scraping the skin 
with the finger-nail. Chloasma having attained a certain size 
extends itself generally slowly ; tinea versicolor grows perceptibly, 
generally until a large area is covered. 

Treatment. — Owing to the disfigurement which lentigo and, 
more especially, chloasma occasion, treatment is frequently called 
for. Attention should be first directed to the cause of the affec- 
tion, which in the case of chloasma may sometimes be determined. 
The suitable remedies, depending upon the condition, are then to 
be prescribed and persevered in. 

Benefit may be obtained from the use of external agents, which 
are applied with a view of acting directly upon the epidermis and 



374 HYPERTROPHIES. 

destroying the accumulated pigment. Among the various remedies 
which have been employed for this purpose, corrosive chloride of 
mercury, ammoniated mercury, subnitrate of bismuth, potash soap, 
sulphur and its preparations, tincture of iodine, acetic acid, and 
hydrochloric acid, may be mentioned. The corrosive sublimate 
is the best, and may be used in the form of a lotion with water, 
almond emulsion, or alcohol; its strength should vary from half 
a grain to five grains to the ounce, according to the susceptibility 
of the skin, the extent of the affection, and the effect produced. 
Two grains to the ounce will in most cases be found sufficiently 
strong. A lotion containing two grains of corrosive sublimate, 
half a drachm of tincture of benzoin, and one ounce of almond 
emulsion is a desirable formula. Hardy speaks well of the follow- 
ing : 

R Hydrargyri Chloridi Corrosivi, gr. viiss ; 

Zinci Sulphatis, ^ss ; 

Plumbi Acetatis, gss ; 

Aquse, 15 i v. 
M. — Sig. Lotion. Apply morning and evening. 

Acetic acid alone or in combination with sulphur, in the form 
of a paste, is favorably spoken of by Neumann. Bulkley gives 
the following : 

R Hydrargyri Chloridi Corrosivi, gr. vi ; - 

Acidi Acetici Diluti, f^ii ; 

Boracis, ^ii ; 

Aquje Rosa?, 15 i v. 
M. — Sig. Lotion. Apply twice daily. 

For the rapid removal of patches, the following method, sug- 
gested by Hebra, may be employed. A solution of corrosive sub- 
limate, five grains to the ounce of alcohol or water, is applied 
continuously by means of compresses. The cloths are to be kept 
moist by the addition of the fluid from time to time, and are to be 
retained in position for about four hours, when the skin will be 
blistered. The epidermis is to be removed and the surface dressed 
with starch powder. The newly-formed epidermis will be devoid 
of pigment. The relief, however, is not apt to be permanent, the 
discoloration usually returning in a variable time. 

Ointments may also be employed. Veratria, from ten to twenty 
grains to the ounce, may be used ; also, strong ammoniated mer- 



CHLOASMA. 375 

cury ointment, and the ointment of the nitrate of mercury, from 
one to four drachms to the ounce of simple ointment. An oint- 
ment composed of one drachm each of ammoniated mercury and 
subnitrate of bismuth to the ounce is favorably spoken of by 
Neumann and others. 

In connection with the subject of chloasma the several discolor- 
ations of the skin due to the deposit of certain pigments may be 
referred to. Although of a different nature, they give rise, accord- 
ing to their cause, to transitory or permanent discolorations, which 
sometimes resemble the chloasmata in appearance. The staining 
due to extravasated blood, as in hemorrhages; to the coloring 
matter of the bile, as in jaundice ; and to the prolonged internal 
use of nitrate of silver, may be mentioned. 

The discoloration of the skin resulting from the internal use of 
nitrate of silver, constituting the condition known as ARGYRIA, is 
of a bluish, bluish-gray, slate, bronze, or blackish color, varying 
as to shade. It occurs over the surface generally, but is more 
pronounced upon those parts ordinarily exposed to the light, as 
the face and hands. According to Riemer* and Neumann,f who 
have made studies of the subject, the pigment, in the form of 
reduced silver, is found in all parts of the skin except the lining 
epithelia of the glands and the cells of the mucous layer of the 
epidermis. The most marked deposit is found immediately beneath 
this layer, being sharply defined as a blackish border. It is made 
up of the minutest granules arranged in groups and in streaks. 
The deposit also takes place in the internal organs. Concerning 
the treatment of this disfigurement, iodide of potassium has been 
suggested by various authors ; but I am aware of only two cases, 
reported by Dr. L. P. Yaudell,J where this remedy, together with 
mercurial vapor baths, has been successfully employed. The 
patients were syphilitic, and took from ten to sixty grain doses 
thrice daily for a period of months. In both cases the fading of 
the discolored skin was gradual ; in one a faint trace remained, in 
the other the cure was complete. 



* Archiv der Heilkunde, 1875 u. 1876. 

f Lehrbueh der Hautkrankheiten, 5te Auflage. Wien, 1880. 

X American Practitioner, Sept. 1872. 



376 HYPEBTEOPHIES. 

Discoloration of the skin is also observed as the result of tattoo- 
ing. In this process the coloring matter, usually vermilion, char- 
coal, gunpowder, or indigo, is inserted into the skin by means of 
needles, and, being insoluble, remains where it has been mechan- 
ically placed. One of the most remarkable examples of a tat- 
tooed individual, where the whole integument was occupied with 
elaborate figures and designs, came under observation a few years 
ago in Vienna.* 

N.EVUS PIGMENTOSUS. 

Syn., Pigmentary Mole; Germ., Pigmentmal ; Fleekenmal ; Fr., Nsevus 
Pigmentaire. 

Pigmentary nsevus may consist simply of a circumscribed deposit 
of pigment in the skin, without hypertrophy of the connective- 
tissue elements or of the hairy system ; or, in addition to the 
excess of pigment there may be hypertrophy of all the cutaneous 
structures, especially the hair. Naevi vary greatly as to size and 
shape ; they may be small, the size of a split pea or bean, or large, 
covering a considerable surface. In shape they may be roundish 
or ovalish, but are often irregular in outline. They are more or 
less deeply pigmented, varying in color from yellowish brown 
to blackish brown. They are Hat, on a level with the surround- 
ing skin, or more or less raised. Their surface is either soft and 
smooth, without change in the texture of the skin, constituting 
N^VUS spilus ; or uneven and furrowed, or rough and warty, 
when the growth is called tsjevub verrucosus. Sometimes they 
are met with as thick, soft, fatty, connective-tissue growths, of 
variable dimensions, the condition being designated xj;vus eipo- 
MATODES. They may or may not possess a growth of hair ; fre- 
quently they are without hair, while in other cases they exhibit an 
abundant growth, which may be cither of the nature of lanugo or 
stiff. When the nsevus is hairy, it is termed NJEVUS pilosus. 

Pigmentary naevi may be single or multiple. f They occur upon 

* The case was reported by Hebra in his Atlas der Hautkrankheiten, Lief. 
VIII., Tafel 10, Wien, 1872. The man was on exhibition in this country. 

f A remarkable case of multiple, monolateral, pigmented naevus, distributed 
in the form of bands of scattered moles, varying in color, occupying the left 
side of the trunk, is reported by Dr. J. Xevins Hyde in the Chicago Med. 
Jour, and Exam., Oct. 1877. A similar ease is recorded bv T. de Amicis in 



MOLLUSCUM EPITHELTALE. 377 

various parts of the body, but are chiefly encountered upon the 
trunk, and more particularly the face, neck, and back. Some- 
times they appear over the course of well-known nerve tracts. 
They are met with in both sexes. They may be congenital or 
acquired. The small, flat, and smooth pigmentary nsevi without 
hair, seen so commonly upon the trunk, are almost invariably 
acquired during the life of the individual. Having attained a 
certain size, which seldom exceeds that of a coffee-grain, to which 
they frequently bear a resemblance in both shape and color, they 
do not incline to grow larger, but remain for a long time without 
undergoing change. On the other hand, the larger, raised, and 
hairy nsevi are usually congenital and permanent growths. The 
coloring matter, consisting of pigment cells and granules, has its 
seat in the mucous layer of the epidermis and in the corium. 
They may be removed by means of the knife or with caustics ; 
when they are small and flat, they may be operated upon with 
potassa or ethylate of sodium. 

MOLLUSCUM EPITHELIALE. 

Syn., Molluscum Sebaceum; Molluscum Contagiosum ; Epithelioma Mol- 
luscum ; Tumores Sebipari ; Molluscum Sessile ; Condyloma Subcutaneum ; 
Fr., Acne Varioliformis; Tumeurs Folliculeuses. 

Molluscum epitheliale is a disease op the epithelium char- 
acterized BY ROUNDED, SEMIGLOBULAR OR WART-LIKE PAPULES OR 
TUBERCLES, OF A WHITISH OR PINKISH COLOR, VARYING IN SIZE PROM 
A PIN-HEAD TO A PEA. 

Symptoms. — Usually they are observed of the size and shape of 
a small split pea. They occur singly or, as is generally the case, 
in numbers, and may ordinarily be seen in various stages of devel- 
opment upon the same patient. Their color is that of normal skin 
or pinkish. They frequently have a decided waxy look, and at 
times resemble a drop of white wax upon the skin. The glistening 
look is due to the skin being stretched. They have also been com- 
pared to small pearl buttons. Upon their summits they are often 

a girl, a dark brunette, aged seventeen. The whole cutaneous surface was 
covered with hundreds of disseminated, blackish-brown, pigmented nsevi, 
varying in size from a pin-head to a bean, some of which were hairy. Upon 
the left palm there existed one the size of a five-cent silver piece. II Mov. 
Med.-Chirurg., Napoli, 1875; also, Lo Sperimentale, March, 1876. 



378 HYPERTROPHIES. 

flattened and have a depression. In the centre a darkish point, 
representing the aperture of the follicle, is commonly present; in 
other cases it is absent. To the touch they are generally firm, their 
consistence depending, however, upon the condition of the contents, 
which is liable to alteration. Their common seat is upon the face, 
especially the eyelids, cheeks, and chin. They are also met with 
upon the neck, breast, and genitalia. They may also occur upon 
the head, and upon the extremities, but are never met with on the 
palms or soles. Rarely, the disease is general. Sometimes the 
lesions are grouped. They have a broad base, and are seated close 
to the surface. They increase in size with variable rapidity, some- 
times rapidly, at other times slowly, and, as a rule, are unaccom- 
panied by inflammatory signs. Occasionally, however, they are 
observed to be the seat of more or less inflammation, when they 
may be mistaken for other diseases. They eventually terminate 
by disintegration and sloughing of the mass. They are accom- 
panied by little or no inconvenience.* 

Etiology. — The disease is not common. It is observed to occur 
chiefly in children, and for the most part among those of the poorer 
class who are neglected and ill fed, but it may also occur in adults. 
Its cause is as yet unsatisfactorily explained. In regard to its 
supposed contagious nature the opinions of careful observers differ 
to such an extent that no conclusion can be reached. Its con- 
tagious nature seems to be more generally entertained in England 
than elsewhere. It is doubtless of much more frequent occurrence 
in that country than here. In my experience in Philadelphia it is 
of rare occurrence. Inoculation with the matter taken directly 
from the tumor, as performed by Hebra, Duckworth, Vidal, and 
others, failed to develop the affection. It must be stated, however, 
that it is not infrequently noted to attack several members of a 
family, from which occurrence it is supposed by some to possess 
contagious properties. On the other hand, its presence limited to 
single cases in overcrowded children's asylums is of equal weight 
against its contagious character. The ground for the proof of its 

* For interesting observations on the disease, consult Hilton Fagge, Guy's 
Hospital Reports, 1870; Dyce Duckworth, St. Bartholomew's Hospital Re- 
ports, vols, iv and viii., 1868, 1872; Hutchinson, Lectures on Clinical Sur- 
gery, vol. i., Part I., London, 1878; and Geo. H. Fox, Chicago Med. Jour. 
and Exam., May, 1878. 



MOLLUSCUM EPITHELIALE. 379 

contagiousness is therefore, I think, at present insufficient. I 
cannot recall a case in which the evidence of contagion appeared 
to me to be conclusive. 

Pathology. — Difference of opinion holds as to the nature of the 
disease, some observers regarding the process as having its seat in 
the sebaceous glands, while others, the majority, maintain that 
it is an affection of the rete mucosum. Among authorities who 
speak in favor of the old view, namely, of its sebaceous nature, 
Kaposi,* Vidal,t Tilbury Fox,J and Hutchinson§ may be quoted. 
On the other hand, many excellent observers, as "Virchow,|| 
Retzius,f Bizzozero and Manfredi,** Lukomsky,ff Boeck,|J 
Simon,§§ Piffkrd,|||| Crocker,«ff gangster,*** and Thin,fft do 
not believe in its sebaceous origin, but hold that the process begins 
in the mucous layer of the epidermis, and is in fact a hyperplasia 
of this structure. If one of the little tumors be incised with a 
knife, the contents may usually be expressed in the form either 
of a consistent whitish or yellowish rounded body, or of a milky 
or thick cheesy fluid or mass. Microscopically, it is seen to con- 
sist of epithelial cells with nuclei in abundance, and peculiar 
bodies, roundish or ovoid in shape, sharply defined, and having a 
fatty appearance, which have received the name of " molluscum 
bodies." 

Virchow's original observations, as follows, are doubtless in the 
main correct. " If a section of one of these tumors be made, an 
appearance as of a lobulated gland is seen. Two distinct parts 

* Vierteljahr. fur Derm, und Syph., IV. Jahrg., 3 Heft (1877). 

f Le Progres Medical, p. 450, June 9, and p. 489, June 23, 1877. 

X Epitome of Skin Diseases, Phila., 1879. 

\ Loc. cit. 

|| Virchow's Archiv, 1865. 

\ Nordiskt Med. Arkiv, Bd. ii. No. 11 ; also Deutsche Klinik, 1871, No. 
50 ; 1872, Nos. 2, 4, 6, 8. Vierteljahr. fur Derm, und Syph , IV. Jahrg., 3 Heft 
(1877). 

** Archiv f. Derm. u. Syph., 4 Heft, 1871, p. 599 ; also 4 Heft, 1876. 

ff Virchow's Archiv, Bd. lxv. 

X\ Vierteljahr. fiir Derm, und Syph., II. Jahrg., 1 Heft (1875). 

l\ Ibid., III. Jahrg., 3 Heft (1876). 

Illl Diseases of the Skin, p. 345. New York, 1876. 

\\ Lancet, vol. i., 1881. 

*** Med.-Chir. Trans., vol. lxiii. 

fff Brit. Med. Jour., Jan. 15, 1881 ; also Jour, of Anat. and Phys., vol. xvi. 



380 HYPERTROPHIES. 

may be recognized : one soft, occupying the interior, which may 
be pressed out, the other firmer, following the walls of the cavity ; 
it is the Malpighian layer greatly developed. The soft substance is 
composed of epithelial cells, polygonal, and mostly without nuclei, 
having depressions, in which one or more peculiar bodies are 
lodged. Nowhere can be seen the fatty granules and oily glob- 
ules which are seen in sebaceous glands. These bodies have the 
greatest resemblance to swollen starch granules. They arc due to 
a peculiar degeneration of the epithelial cells." 

Virchow further considers the disease to begin in the hair- 
follicles, the folded gland-like appearance being due to a hyper- 
plasia of its epidermal lining. The studies of Thin * confirm these 
observations. The growth "begins in the hair-follicle between 
the root-sheaths and the shaft of the hair, but soon takes root 
among the cells in the free surface of the epidermis which sur- 
rounds the follicle. It is attended with a continuous growth of 
epidermis downwards into the cutis, the successive layers of newly- 
formed cells becoming successively the seats of the specific change." 
The nature of the so-called molluseum bodies is regarded differ- 
ently by the authorities quoted, but the opinion generally main- 
tained is that they are cells of the mucous layer which have un- 
dergone change. Kaposi considers them as epidermal cells with 
modified protoplasm, and states that they are not peculiar to 
molluseum, but are found in other diseases. Thin gives the 
development of an epidermic cell into a molluseum body as fol- 
lows: "The first certain change is that of the cell becoming 
filled with minute granules, the nucleus remaining entire and 
being generally found near the wall of the cell. Clear spaces are 
seen in this granular substance, — so-called vacuoles. In succeed- 
ing stages the granules become larger and fuse into a homoge- 
neous substance, the nucleus in the mean while losing its spherical 
form and becoming finally lost. In the ultimate stage, this ho- 
mogeneous substance fills the whole of the cell, which is then 
known as a molluseum body, but the cell-wall is not involved 
in the change, and retains its epidermic character. In the final 
stages the molluseum substance may fall out and leave behind it 
the horny capsule in which it was contained." 

* Loc. cit. Jour, of Anat. and Phys., vol. xvi. p. 206. 



MOLLUSCUM EPITHELIALE. 381 

Diagnosis. — Molluscum epitheliale should not be confounded 
with molluscum fibrosum. These two kinds of tumor may be 
readily distinguished by their anatomical characters. In epithe- 
lial molluscum the opening of the follicle is usually to be seen as a 
darkish point in the centre of a slight depression on the apex of 
the tumor. The growths of molluscum fibrosum are made up of 
a connective-tissue new formation, firmly seated in and beneath 
the skin, and possess a firm, fibrous feel. The little tumors of 
molluscum epitheliale usually occur about the face, and in limited 
numbers ; those of molluscum fibrosum commonly appear about 
the body, and often in great numbers. The tumors of epithelial 
molluscum are prominently raised from the skin, and are super- 
ficial in their seat; those of molluscum fibrosum are located in 
the skin itself, and even in the subcutaneous tissues. Molluscum 
epitheliale is, as a rule, a disease of infancy and childhood ; mol- 
luscum fibrosum is an affection of adult life. The disease is also 
to be distinguished from papillary warts. The resemblance be- 
tween these two affections is often marked, particularly in those 
cases of molluscum which are imperfectly developed, the growth 
assuming more of an acuminated than of a rounded form. 

Treatment. — Local remedies alone are required to relieve the 
disorder. Where the lesions are small or numerous, they may be 
treated with one of the stimulating ointments, as white precipitate 
or sulphur ointment. The larger tumors are to be treated sepa- 
rately, and may be removed by the knife ; they may also be de- 
stroyed by means of mild caustic applications. Free but careful 
incision upon the top of the tumor is the best treatment, after 
which, in the majority of cases, the mass may be easily forced out 
of its seat. If adherent, it should be extracted with the forceps. 
Nitrate of silver may be applied to the cavity and base after enu- 
cleation. When the opening of the follicle is widely distended, 
the contents may sometimes be squeezed out by firm pressure with 
the fingers against the sides of the tumor. They may also be 
treated with a ligature, when their bases are to be touched with 
nitrate of silver. Whatever the method of treatment adopted, it 
should never be heroic, for it must not be forgotten that the affec- 
tion tends to spontaneous recovery. 

Prognosis. — The disease is amenable to treatment, which, if 
properly carried out, is rarely followed by a return of the affec- 



382 HYPERTEOPHIES. 

tion. If, on the other hand, the growths are only partially 
destroyed, they are apt to form again. 

CALLOSITAS. 

Syn., Tvloma ; Tylosis ; Callus ; Callosity. 

CALLOSITAS CONSISTS IX THE FORMATION OF A HARD OR HORNY, 
THICKENED PATCH OF SKIN, VARIABLE AS TO SIZE AND SHAPE, GRAY- 
ISH, YELLOWISH, OR BROWNISH IN COLOR, UNATTENDED BY PAIN, 
OCCURRING FOR THE MOST PART ABOUT THE HANDS AND FEET. 

Symptoms. — The skin is increased in thickness, and presents a 
firm, dense, more or less circumscribed structure. The degree of 
hardness varies considerably, sometimes being horny. The patches 
are usually the size of a coin, are apt to be roundish in shape, and 
possess a variable amount of elevation above the surrounding skin. 
In color they are grayish, yellowish, or brownish ; this, however, 
is influenced by the amount of friction to which the part is -ob- 
jected, and the occupation of the patient. They usually have 
their seat upon the palms, fingers, soles, and toes, and more par- 
ticularly about parts exposed to pressure. They are frequently 
encountered upon the hands of mechanics and others who use t<>,,]~, 
as shoemaker.-, smiths of various kinds, and carpenters. They are 
seen also upon the fingers of violin and harp players. Upon the 
feet they occur for the most part about the soles, particularly 
about the ball of the great toe and upon the side of the little toe. 
They may remain unchanged for a long time, or they may un- 
dergo spontaneous involution, after the cause has been removed. 
Their development is always gradual. Inflammation, occasionally 
terminating in an abscess, may now and then accompany them. 

Etiology. — They are, in the majority of instances, caused by 
external influences; at times, however, they appear to be devel- 
oped independently of any exciting or external cause. Usually 
they will be found to depend upon the continued application of 
pressure or friction, as in the case of the hand of the mechanic, 
the effect of his tools; or, if upon the foot, they will be noticed 
to result from the wearing of ill-fitting shoes, or from unusual 
walking. They are toramoner in men than in women, and may 
occur at any age, although they are more often encountered in 
middle and old ao-e. 



clavus. 383 

Pathology. — The patch of callus is a simple structure, made up 
of numerous layers of epidermis, which have accumulated one 
upon the other. A transverse section, as Simon* has shown, 
reveals an hypertrophy of the horny layer, the corium remaining 
normal. The cells of the epidermis become so closely packed as 
often to simulate horn substance. 

Treatment. — When the callosity is a source of inconvenience, it 
may be best removed by means of the knife. The part should 
be repeatedly soaked in warm water, when it will become more 
or less softened, and will permit of being pared or scraped off, 
layer by layer, with a sharp knife. A poultice may also be used 
for the same end. Caustic potash solution in varying strength, 
suitable to the part to be attacked, will also prove serviceable : it 
is, however, to be employed cautiously, lest it work its way down 
and destroy the papillary layer. Where the formation is the re- 
sult of the occupation, it is not advisable to remove it; not infre- 
quently it ceases after a time to be produced, and in this event 
disappears spontaneously., 

CLAVUS. 

Syn., Corn ; Germ., Leichdorn ; Huhnerauge; Fr., Cor. 

Clavus is a small, circumscribed, usually flat, deep-seated, 
more or less horny formation, painful upon pressure, situ- 
ated for the most part about the toes. 

A corn usually presents the general outward appearance of a cal- 
losity. It is made up exteriorly of thickened skin, is often more 
or less polished upon its surface, and has a hard, horny feel. On 
the other hand, it may be soft, possessing features similar to those 
of the wart. It is rounded and circumscribed, varying in size 
from a pin-head to a small split pea. It is painful upon pressure, 
and frequently is accompanied by shooting sensations independently 
of pressure. If the cause which occasioned the corn be kept up, 
inflammatory symptoms may develop. The common seat of corns 
is the outer surface of the little toe; they also occur between the 
toes, and upon the soles of the feet. Existing between two toes, 
the corn is accompanied by more or less maceration, and appears 

* Die Hautkrankheiten, p. 29. Berlin, 1851. 



384 HYPERTEOPHIES. 

as a soft or spongy formation, which receives the name of soft corn 
in contradistinction to the hard corn. One, two, or a number of 
corns may be present, in which case they interfere with walking 
or even with standing. 

Etiology. — They are the result either of continued pressure or 
friction, and in the vast majority of cases may be referred to im- 
properly-fitting or tight shoes. 

Pathology. — The growth is made up of a circumscribed, ex- 
cessive development of the epidermis, of the same character as 
that observed in callosity, and of a central portion, or core. The 
latter extends quite deeply into the tissues, in the form of an in- 
verted cone, the base being directed outwards, and appearing upon 
the surface as a rounded spot. It consists of a whitish, opaque, 
firm, tenacious body, with its apex resting upon the papillary 
layer of the corium. In structure, it is composed of epidermic 
cells, arranged in concentric laminae. One or more cores may 
exist. The corium beneath may be either atrophied or hypertro- 
phied. The pain attending corns is produced by the core pressing 
upon the true skin, causing irritation of the nerve filaments of the 
papillae. It is often intermittent. 

Treatment. — If the cause be removed, the treatment is suffi- 
ciently simple. On the other hand, if improperly-fitting shoes 
and other causes be persisted in, much delay and difficulty may be 
experienced in relieving the condition. If the patient is obliged 
to walk much, the corn should be protected by a piece of cut felt 
or surrounded by narrow strips of adhesive plaster. The foot 
should be frequently soaked in warm water, after which the outer 
layers will be macerated and may then be removed by scraping or 
picking with a pointed knife. A bread and milk poultice, applied 
to the part by a bandage before retiring, and kept on all night, will 
generally give relief. This treatment, repeated for several nights 
in succession, will soften the growth to such an extent that it may 
in some cases be extracted from its bed. Various plasters are 
recommended, most of which consist of resin, galbanum, or pitch, 
together with acetic acid, subacetate of copper, chloride of ammo- 
nium, carbonate of potassium, and like substances. Diachylon 
plaster may also be used. Nitrate of silver, in solid stick form, 
may be used with advantage after the corn has been sufficiently 
softened, and will be found useful in soft corns occurring between 



CORNU CUTANEUM. 385 

the toes. A coating of flexible collodion may be employed in 
painful soft corns. Potassa with water or alcohol, half a drachm 
or a drachm to the ounce, may be applied where the epidermis 
is hard and thick; the application should be made with care, and 
only to the part to be acted upon. 

CORNU CUTANEUM. 

Syn., Cornu Humanum ; Cutaneous Horn; Horny Excrescence ; Horny- 
Tumor; Germ., Hauthorn ; Fr. } Production Cornee; Corne de la Peau. 

Cornu cutaneum is characterized by the development of a 
true horny formation arising from the skin, variable as to 
size and shape. 

Symptoms. — When fully developed, the excrescence is a veri- 
table horn, differing but slightly, if at all, from that found nor- 
mally upon the lower animals. It is a solid, hard, dry formation, 
and is observed to have a more or less laminated, wrinkled, 
roughened, uneven surface. In form it is usually elongated and 
roundish or conical; occasionally it assumes a flattened form, in 
which case the growth is but little elevated above the surrounding 
skin. Horns vary as to shape, but are apt to be crooked, twisted, 
and bent, being rarely straight, and terminate either pointedly or 
with a blunt end. Their color is usually grayish, but they may also 
be yellowish, brownish, or blackish. They grow to all sizes, vary- 
ing from a few lines to many inches, their diameter being greater 
at the base than at the free extremity. They possess a concave 
or flattened base, which rests directly upon the skin, from which 
they spring abruptly. The tissues about their bases may be either 
normal or somewhat elevated ; at times they are surrounded by 
an areola or by marked inflammation, which may be followed by 
suppuration. 

Horns are usually solitary; occasionally, however, they are 
multiple. Botge* describes two cases, one in a man aged sixty 
who had six horns, four on the nose and two on the left cheek. 
The second case was that of a girl aged nineteen, who in her second 
year had an extensive eruption, which was followed by wart-like 

* Deutsche Zeitschrift fur Chir,, Bd. vi., 1876; also, Viertelj. fur Derm, 
und Syph., Heft 1 u. 2, 1877. 

25 



386 HYPEETEOPHIES. 

growths. The lower portion of the body, from the crest of the 
ilium down, was studded with a great number of disseminated and 
grouped horns of various sizes. The gluteal regions were thickly 
and symmetrically set with them. Close to the navel there was a 
horn about six inches in height; while on the right labium there 
was one but a trifle shorter. 

They may appear upon any region of the integument, but are 
more common about the face and scalp. Pick* records a case 
where the growth, originating in acuminated warts, occupied the 
penis, springing from the sulcus around its whole circumference. 
It was two inches in length and about half an inch in thickness. 
The patient was only twenty-two years of age, and the growth of 
but six months' duration. Jewettf noted a case where the horn 
measured three and three-quarter inches in length. A similar 
case is reported by Wilson.J Nine cases of horns of the penis are 
referred to by Pick. 

They seldom make their appearance before the age of forty or 
fifty ; they have, however, been met with in the young. As a 
rule, they are unattended by pain, but if knocked or disturbed 
they may subsequently be accompanied by uneasiness or pain 
about their bases. Their course is slow, growing with variable 
rapidity until they arrive at a certain size, when they not infre- 
quently become loose and drop off, leaving an open, ulcerating base. 
When this takes place, they are very liable; to be reproduced. 

Etiology. — The causes are not satisfactorily determined. The 
affection is a rare one. A number of reported cases have been 
collected by Lebert,§ Wilson, || Bergh,^ and Damon.** An in- 
teresting case (with photograph) has been reported by Pancoast.ft 
Porcher^ reports an instance where the horn measured seven 



* Two colored plates accompany the article. Viertelj. fur Derm, und Syph., 
187-3. p. 315. 

f New York Med. Times, 1853. 

X Lectures on Dermatology. London, 1878. 

\ Ueber Keratose oder die durch Bildung von Hornsubstanz erzeugten 
Krankheiten und ihre Behandlunir. Breslau, 1804. 

|] Medico-Chirurgical Trans., 1844, vol. xxvii. p. 52. 

\ Archiv fur Derm, und Syph., 1873, Heft 2, p. 185. 

** Structural Lesions of the Skin. Phila., 1809. 

ft Phot. Key. of Med. and Surg., vol. i. No. 1, 1870. 

%\ Charleston Med. Jour, and Rev., 1855. 



VERRUCA. 387 

inches in length and two and three-quarter inches in diameter, 
which sprang from the forehead of a n egress. 

Pathology. — According to Lebert,* cutaneous horns spring from 
the deeper strata of the mucous layer of the epidermis, and consist 
of a hyperplastic growth of these cells. Inasmuch as this layer 
is present not only immediately above the papillae of the coriura, 
but also as a lining membrane in the follicles and glands, it will 
be seen that the disease may start in these latter structures quite 
as readily as from the free surface of the epidermis. Microscopic 
examinations by the same observer show longitudinal sections to 
be made up of a mass of "small columns, rods, or palisades lying 
close to one another, and so intimately united by a connecting 
substance as to appear blended into a homogeneous mass. The 
individual columns have a striped, shreddy appearance, and are 
made up entirely of epidermic cells arranged upon one another 
in an imbricated manner." Transverse sections show roundish 
spaces, concentrically stratified, between the layers of which exist 
irregularly-placed epidermic cells, which are to be viewed as the 
connecting substance referred to in considering the longitudinal 
sections. The cells, as might be expected, are for the most part 
without nuclei, always belonging to the epidermic variety. Both 
Lebert and Virchow have demonstrated the presence of blood- 
vessels in the bases of horns. The character of the cutaneous 
base from which the excrescence proceeds is found to vary. 

Treatment. — After the horn has been detached from the skin, it 
is a necessary part of the treatment to destroy the base by means 
of some caustic, for which purpose chloride of zinc or caustic 
potash may be used. If there be a tendency to reproduction, the 
operation should be repeated. 

VERRUCA. 

Syn., "Wart; Germ , Warze ; Fr., Verrue. 

Verruca is a hard or soft, rounded, plat, or acuminated, 
circumscribed, papillary formation, variable as to size. 

Symptoms. — The wart presents itself in a number of forms, 
which are so different as to require separate descriptions. 

* Loc. cit., p. 76. 



388 HYPERTROPHIES. 

Verruca Vulgaris. — This is the ordinary wart, commonly 
met with on the hands. It consists of a small, circumscribed, 
usually split-pea sized and shaped, elevated growth, with a broad 
base, seated securely upon the skin. It is soft or firm in consist- 
ence, or may even be hard, with a horny exterior. The surface is 
observed to be either smooth or rough, and to be studded with 
a number of minute elevations, — hypertrophied papilla?. These 
may be so irregularly developed as to give it a divided or lobu- 
lated appearance. The color is either that of the surrounding 
skin or darker; at times it is .yellowish, brownish, or blackish. 
One, several, or great numbers may exist; they are apt to appear 
in groups, and commonly are in such close proximity as to touch 
and press upon one another. Their usual seat is about the hands, 
especially the fingers, but they may show themselves upon any 
region. 

Verruca Plana. — This differs from the above-mentioned 
variety in being flat and broad in form. They are usually the 
size of a split pea or a small finger-nail, and are but slightly ele- 
vated above the level of the surrounding skin. They occur either 
singly or in numbers, and are seen most frequently upon the back, 
especially in elderly people, when they are apt to be brownish or 
blackish in color (Verruca senilis, Keratosis pigmentosa). Not 
infrequently they are met with as very small, flat, rounded, dis- 
crete or confluent formations on the forehead and other regions 
of the face (Verruca? minima?). Sometimes they develop in great 
numbers, 'especially on the face. 

Verruca Filiformis. — This variety assumes the shape of a 
small, thin, conical, or thread-like formation, usually about an 
eighth of an inch in length. They may appear either singly 
or in groups; rarely, however, do they occur in numbers. They 
are principally encountered on the face, on the eyelids, and on the 
neck. 

Verruca Digitata. — The formation here, as in the case of 
the flat wart, consists of a slightly elevated, broad excrescence, 
varying in size from a split pea to a large finger-nail, and marked 
by a number of digitations coming from its border ; these are often 
greatly developed, and give to the growth an appearance resembling 
a crab. They are commonly seen upon the scalp, where they may 
exist in numbers. 



VERRUCA. 389 

Verruca Acuminata.* — This variety consists of one or more 
groups of acuminated or irregularly-shaped elevations, usually 
so closely packed together as to form a more or less solid mass 
of vegetations (Verruca? vegetantes). The individual prominences 
vary considerably as to form ; they tend to be pointed or tufted, but 
they may also be club-shaped, and in some cases exist as thick, 
short, fleshy excrescences, giving the growth the appearance of 
granulation tissue. They may be either sessile or pedunculated. 
In color they are pinkish or reddish ; at times they are bright red, 
in other cases purplish, the shade depending upon the degree of 
vascularity and the region in which they happen to exist. They 
occur for the most part about the genitalia of either sex, more 
particularly about the penis and labia. Upon the penis they 
usually spring from the glans and the inner surface of the pre- 
puce; upon the female they generally start from the inner surfaces 
of the labia and from the vagina. They are also encountered 
about the anus, mouth, axillse, umbilicus, and toes. According 
to the region in which they are present, will they be dry or moist; 
about the genitalia, a yellowish, puriform secretion usually covers 
their surface, due to friction and maceration, which owing to the 
heat of the parts rapidly decomposes, producing a highly offensive 
substance. Crusts, made up of secretion and blood, are also not 
infrequently present. The odor from these condylomata is usually 
of a penetrating and disgusting character. They may attain a 
large size ; not uncommonly they grow as large as a hen's egg, and 
at times to the size of a fist-. According as they happen to be 
arranged and distributed, they present different appearances ; they 
have been aptly compared to a head of cauliflower, to a cock's 
comb, to fungi, to raspberries, arid to other forms of vegetation. 
Their development is rapid ; not infrequently they attain con- 
siderable size in the course of a few weeks. They generally ap- 
pear as luxuriant growths, tending to increase in size and to mul- 
tiply ; without interference they may assume large proportions and 
continue for an indefinite period. They are met with in both men 
and women, and are usually encountered in young people. 



* Termed also Pointed Wart, Moist Wart, Fig Wart, Pointed Condyloma, 
Cauliflower Excrescence, Yerruca Elevata, Venereal Wart ; Ge?-m., Spitze 
Condylom ; Fr., Vegetation Dermique. 



390 HYPERTROPHIES. 

Etiology. — The causes which give rise to warts are obscure. 
The various influences which are popularly assigned as causes, 
most of which are widely different in their nature, are, it need 
scarcely be stated, incapable of producing the disease. They occur 
in both sexes, and are much more common in the young than in 
the old. They are very common in children. They incline to 
appear in those of scrofulous habit. 

In regard to the acuminated variety, or pointed condylomata, it 
is well known that they are often caused by the irritating secre- 
tions of venereal disease, more especially gonorrhoea; but they are 
never a manifestation of constitutional syphilis. The vegetating 
Byphiloderm must not be confounded with this growth. 

Pathology. — The anatomy of warts differs somewhat according 
to the variety, but in all forms there exists as a basis a connective- 
tissue growth, from which papillary hypertrophy takes place. The 
interior of the formation is supplied by one or more vascular loops, 
from which the structure obtains its vitality. In the common, 
hemispherical wart, the papillae become greatly thickened and 
elongated, and are covered with a hypertrophic layer of epidermis, 
which gives it the hard or horny exterior. 

The pointed warts, or condylomata, are exceedingly vascular, 
and are made up chiefly of connective-tissue elements, which form 
a mass of firm consistence. The papillae are enormously hyper- 
trophied, and are covered with an exuberant and extensive mucous 
layer, the cells of which are highly developed. The horny layer 
is seldom formed to any extent; but this is found to vary accord- 
ing to the locality in which the growth occurs. 

Treatment. — Excision, by means of the knife or scissors, in 
many instances affords the most satisfactory results, the operation, 
as to the manner of cutting, varying somewhat with the form of 
Mart under consideration. Many of the smaller formations are 
best removed by a pair of curved scissors, their bases being touched 
with the nitrate of silver stick. The dermal curette, or scraping 
spoon, may also be employed, especially in connection with other 
remedies. The ligature and the galvauo-caustic wire may be ad- 
vantageously employed where the growth is liable to be attended 
with hemorrhage, as in cases of acuminated warts about the geni- 
talia. These may also be successfully treated by washing the parts 
with the liquor soda? chlorinatae and afterwards dusting with calo- 



VEEEUCA. 391 

mel ; or, with nitric acid or chromic acid. Carbolic acid also 
acts well. A powder composed of equal parts of burnt alum 
and powdered savine may likewise be used. 

Common warts may, moreover, be treated satisfactorily by the 
application of various caustics, among which potassa, nitrate of 
silver, acid nitrate of mercury, chloride of zinc, nitric acid, chro- 
mic acid, hydrochloric acid, and acetic acid may be mentioned. 
Caustic potash, nitrate of silver, and chromic acid, in solution, will 
be found the most useful ; in the case of the two latter substances, 
repeated applications may be required. Tincture of the chloride 
of iron may also be mentioned. In selecting a remedy, the variety 
and size of the growth, as well as the locality in which it occurs, 
should be considered. The strength of the solution is to be regu- 
lated according to the nature and exterior covering of the wart. 
In making the application of fluid substances, care should be ex- 
ercised to protect the adjacent healthy skin ; a layer of soft wax 
placed immediately around the growth will prevent the caustic 
from attacking the sound skin. In the case of multiple flat warts, 
precipitated sulphur made into a paste (at the time of using) with 
glacial acetic acid and glycerine, equal parts, may be employed 
with good result. McCall Anderson regards the use of arsenic 
internally with favor.* 

Prognosis. — This is favorable. Sometimes, however, they are 
very obstinate. Where they are numerous or of large size, it is 
advisable not to undertake the removal of the whole mass at one 
time. Hemorrhage should be guarded against. 

Papilloma. — The true papilloma of the skin, of which Hard- 
away'sf case may be taken as an example, is an inflammatory for- 
mation or tumor, variable as to size, made up of a growth very 
similar to that of the acuminated wart, or condyloma. It consists 
of a flat or raised, cauliflower excrescence, reddish or bluish in 
color, showing hypertrophy of the papillae. Fissures and sinuses 
are apt to be present, which secrete a yellowish, puriform fluid. 
The course of the disease may be rapid or slow. It may appear 
upon any region of the body, and at any time of life. It is of a 
benign nature, and is not due to syphilis. 

* Treatment of Skin Diseases, p. 56. London, 1877. 
f Arch, of Derm., Oct. 1880. 



392 HYPERTROPHIES. 

Hardaway* considers the subject of papilloma from an etiologi- 
cal stand-point, stating that, however desirable it might be to retain 
the term for a substantive disease, this is not possible in the present 
state of our knowledge. One of the chief forms of the disease 
has been called "neuropathic papilloma," which is characterized 
by more or less pigmented papillary growths, limited to one side 
of the body, and following the distribution of the cutaneous nerves. 
Cases have been reported under the various titles of " verrucous 
naevus," "naevus papillaris," "naevus unius lateris," nerve nsevus, 
"neuropathic papilloma," "papilloma neuroticum," and "ichthy- 
osis hystrix congenita," by A. S. Thompson,f Biirensprung,! 
Th. Simon, § Neumann, || Gerhardt,^[ Mackenzie,** Crocker,ff 
Curtis,JJ and Hardaway.§§ Another variety of the disease is 
that called by Hardaway "symptomatic papilloma," characterized 
by papillary fungoid growths following upon various primary 
conditions, as syphilis, lupus, etc., unusual instances of which are 
described by Weil, |||| Roser,^ and Charpy.*** Hardaway fff 
reports a case of "general idiopathic papilloma," apparently pri- 
mary in character, marked by the eruption of variously sized and 
situated fungoid excrescences. 

A peculiar form of disease may here be referred to, described 
by Kaposi,!!! which he terms " dermatitis papillaris capillitii." 
Hardaway designates it "local idiopathic papilloma," and records 
a case in a negro. It is characterized by pin-head sized discrete 

* Arch, of Derm., Oct. 1880. 

f Atlas of Delineations of Cutaneous Eruptions. London, 1820. 

% Quoted by Neumann in his Lehrbuch der Hautkrankheiten, "Wien, 
1876. 

\ Archiv fiir Derm. u. Syph., 1872. 

|| Wiener Med. Press.-, No. 51, 1877 ; also Arch, of Derm., Oct. 1878, p. 368. 

\ Jahrb. fiir Kinderheilk., 1870-71, N. F. 

** Med. Times and Gaz., April 24, 1880. 

ft Ibid., June 12, 1880. 

++ Arch, of Derm., July, 1880. 

\\ Ibid., Oct. 1880. 

Illl Das entziindliche Hautpapillom. Yiertelj. fiir Derm. u. Syph., Heft 1, 
1874. 

\\ Das entziindliche Hautpapillom. Archiv der Heilkunde, 1866. 

*** Annales de Derm, et de Syph., No. 1, 1872-73. 

fff Loc. cit. 

J+l Path, und Ther. der Hautkrankheiten. 'Wien, 1880. 



ICHTHYOSIS. 393 

or confluent papules, which pass into scar-like patches upon which 
the hairs appear bunched in the form of tufts, while in other places 
baldness exists. The hairs are extracted with difficulty or break 
off, and show a twisted, atrophic condition. The disease begins 
usually at the border of the scalp on the back of the neck, and 
extends itself over the occiput, where elevated, papillomatous, 
secreting and bleeding, crusted, offensive vegetations generally 
form. Kaposi considers the process to be an idiopathic inflam- 
matory one, having no relation with syphilis. 

ICHTHYOSIS. 

Syn., Xeroderma; Xeroderma Ichthyoides ; Ichthyosis Vera ; Ichthyosis 
Congenita; Fish-skin Disease; Germ., Fischschuppenausschlag ; Fr., Ich- 
thyose. 

Ichthyosis is a congenital, chronic, hypertrophic disease, 
usually occupying the whole surface, characterized by dry- 
ness, harshness, or scaliness of the skin, and a variable 
amount of papillary growth. 

Symptoms. — Two varieties of the disease are encountered, named 
ichthyosis simplex and hystrix; they may occur independent of 
each other or, as not infrequently is the case, together. The dis- 
ease varies exceedingly in the degree of its development. In one 
individual it amounts to but a slight inconvenience; in another it 
manifests itself in so pronounced a manner as to be the source of 
great discomfort and deformity. 

Ichthyosis Simplex. — This is the variety usually met with. 
When simple dryness and harshness only of the skin exist, with 
more or less furfuraceous exfoliation, but without the formation of 
plate-like scales, the condition is termed xeroderma. This is the 
mildest type of the affection. As ordinarily encountered, however, 
it consists of an altered state of the skin, characterized by a harsh, 
dry condition of the whole surface, accompanied by the production 
of variously sized and shaped, reticulated scales. These are either 
small, thin, and furfuraceous, like bran, or they are large and thick, 
resembling fish-scales, and are shaped after the normal lines and 
farrows of the part on which they exist. Upon the extremities 
they usually form diamond-shaped or polygonal plates, separated 
from one another by furrows or lines, which extend down to the 



394 HYPERTROPHIES. 

normal skin.* The amount of scaling present will depend upon 
the age of the patient, the severity of the disease, and the external 
treatment, as, for example, bathing, to which the skin has been 
subjected. If the scales be not removed from time to time, they 
tend to accumulate into laminae of considerable thickness. In color 
they are usually whitish, grayish, or yellowish, and often have a 
silvery or glistening look ; in other cases they are of a yellowish 
olive-green ; while more rarely they are dark olive-green or blackish. 
Even in those cases where the affection is but slightly developed, 
the skin usually possesses a dirty, yellowish tint, as though it had 
not been recently washed. 

Ichthyosis Hystrix. — This variety varies greatly as to the 
extent of its development ; it may exist in the form of one or 
more localized patches, or as a diffused disease, involving the 
greater portion of the surface in an unevenly distributed manner. 
It is characterized by irregularly sized and shaped, ill-defined, 
rough, harsh, yellowish, brownish, or greenish patches, which are 
made up of enormously hypertrophied, more or less horny papillae. 
These patches, or areas of disease, may occur upon any part of the 
body. I have seen them upon the arms as solid, warty patches; 
upon the back in the form of elongated, linear patches ; about the 
folds of the axillae, around the neck, around the umbilicus, and 
upon other regions. A number of regions are apt to be the scat 
of disease in the same patient; in other case- the growths appear 
upon, for example, an arm or the back only. They are usually 
very irregular in shape, adapting themselves in outline to the 
region upon which they exist. Sometimes they are seated over 
well-known nerve tracts. They may constitute roughened, cor- 
rugated, papillary growths, or they may result in uneven, horny, 
blunt or pointed, spinous, warty formations. In the latter case 
the elevations may reach several lines or more, and stand out 
from the skin like quills upon the back of a porcupine, — hence 
the name hystrix. f Like ichthyosis simplex, this variety varies 



* This is well shown on the thigh in Plate F of my Atlas of Skin Diseases ; 
also in Fox's Photographic Illustrations of Skin Diseases, Part II., repre- 
senting a milder form of the disease. 

f A portrait of an unusually developed ease may be found in Hebra's Atlas 
of Skin Diseases, Lief III. TYien, 1859. 



ICHTHYOSIS. 395 

materially according to the age of the individual in whom it 
is seen ; the older the patient the more highly developed will it 
usually be. 

Ichthyosis simplex usually involves the whole surface, more or 
less generally, although it always manifests itself more markedly 
in certain regions ; these are the lower extremities, from the hips 
dowu to the ankles; and the arms and forearms. The knees and 
elbows are in almost all cases the seat of considerable wrinkling, 
thickening, roughness, and scaliness. On the other hand, the 
flexures of the elbows and knees, as well as the axillae and the 
groins, seldom show the disease. The difference between the 
outer surfaces of the joints and the flexures is generally striking. 
The scalp and face rarely exhibit the disease in a marked degree. 
The scalp and hair, however, are usually dry, and the latter is 
more or less harsh or brittle. .The skin of the hands and feet is 
always dry and wrinkled, the natural lines of motion being deeply 
furrowed. The hands and feet are usually cold. The soles of 
the feet show marked epidermic thickening and sometimes callosi- 
ties. The backs of the feet and ankles occasionally develop thick 
masses of scales, which assume the form of small polygonal plates, 
resembling somewhat both in appearance and in conformation the 
skin of the alligator. These epidermic plates are at times dark- 
greenish or blackish in color (ichthyosis nigricans). 

Ichthyosis is always worse in winter than in summer. In the 
majority of cases it is only at this season of the year that the 
affection gives rise to inconvenience. It usually disappears more 
or less completely during the spring and summer. Even those 
instances in which there is marked papillary hypertrophy are 
greatly influenced and modified by warm weather. Ichthyotic 
persons are noted to perspire but slightly. Sensible perspiration 
usually takes place only from certain localities, as the axilla?, face, 
palms, and soles. The increased activity of the sweat glands in 
summer, and the effect of this secretion upon the epidermis, pro- 
duce the most beneficial results, often relieving the patient of his 
disease almost entirely for the time. 

The course of the disease is essentially chronic. It continues 
throughout life, varying in its severity with the seasons. The 
subjective symptoms are of little importance. At times there is 



396 HYPERTROPHIES. 

slight itching, which usually comes on when the skin is exposed 
to the air, as when the clothing is removed at night. 

Etiology. — The affection is to be regarded as one which is born 
with the individual ; ordinarily, however, it does not manifest 
itself until after the first or second year of life. At first the 
disease is slight, but year by year it becomes more marked until 
adult age is reached, when it ceases to increase in intensity, and 
remains in this condition through life. It is hereditary in some 
cases, but not in all. Instances often present themselves in which 
one or the other parent is similarly affected ; other cases, accord- 
ing to my experience, not infrequently occur in which neither 
parents nor grandparents are found to have any trace of the 
disease. One child only out of a large family may be affected ; 
in other cases more than one may show signs of it. The parents 
of ichthyotic children are usually healthy and without constitu- 
tional vice. The subjects themselves of ichthyosis commonly 
enjoy the best of general health. The condition, then, is to be 
considered in the light of a simple deformity, similar from an 
etiological point of view to nrevi, albinism, and other like struc- 
tural defects. It occurs in both sexes, is common to all races, 
and is found in all spheres of society. According to the statistics 
of the American Dermatological Association, 36 cases only were 
encountered in 16,863 cases of skin disease; but the affection is 
commoner than these figures indicate. 

Pathology. — The changes which exist in ichthyotic skin will be 
found to differ materially as one form or another of the disease is 
examined. Thus, slight ichthyosis — xeroderma — offers an alto- 
gether different picture from the severer type hystrix. The disease, 
however, may be said to consist in an excessive proliferation of the 
cells of the epidermis, together with more or less hypertrophy of 
the papillae of the corium. In a section of ichthyosis of ordinary 
development the horny layer will be observed to be enormously 
increased in thickness, and to be dry and of a yellowish color; 
the mucous layer will also be seen to be augmented by new cells. 
The papillae are longer than normal, and are infiltrated with cells; 
the vessels are also enlarged. Kohu* found, in a typical case of 
ichthyosis hystrix, that the disease began in the vascular layer of 

* Archiv fur Derm, und Syph., 1869, Heft 3, p. 418. 



ICHTHYOSIS. 397 

the corium. The papillae were conically elongated, and widened 
about their bases, the enlargement taking place by means of a 
growth of new connective tissue. The mucous and horny layers 
were largely increased, and were found to be made up of a number 
of laminae. 

Diagnosis. — The features of the disease are of so peculiar a 
character that but little difficulty is experienced in arriving at 
the diagnosis. The harsh, dry, wrinkled skin; the hypertrophic 
epidermis ; the enlarged papillae ; the thin, yellowish scales ; the 
deep farrows and lines, especially about the joints ; the diffused 
distribution of the affection, and the regions particularly affected, 
all point to ichthyosis, and to this disease only. Added to these 
objective symptoms, the history, in the case of an adult, will aid 
in establishing the diagnosis. It will be distinguished from the 
inflammatory disorders which tend to terminate in desquamation, 
by the absence of any history of inflammation. 

Treatment. — External treatment is alone found to be of service. 
Various internal remedies, including iron, arsenic, cod-liver oil, 
and iodide of potassium, have from time to time been employed, 
but without benefit. Local therapeutics, however, exert a favor- 
able influence upon the affection, and, at the present day, constitute 
the method of coping with the disease. Of the several remedies 
used, water is to be mentioned first as being one of the most valu- 
able, in the form of baths, either simple or medicated. Its action 
upon the skin is a mechanical one, macerating the accumulated 
masses of epithelial matter and exposing young layers of epidermis, 
which are found to be comparatively soft and pliable. The relief 
thus obtained is temporary, but nevertheless affords the patient 
ease and comfort for the time, and, when persevered in, may so 
modify the skin as to retard the hypertrophy. It may be stated, 
then, that, as a rule, the more frequently the ichthyotic patient 
bathes, and the longer he is able to remain in the water, the less 
will the deformity show itself. Vapor baths are particularly 
serviceable; also alkaline baths, containing from two to eight 
ounces of the bicarbonate of sodium to the bath. Some cases, 
however, do not improve under alkaline baths, when the treat- 
ment with soap, to be referred to, may often be instituted with 
better result. 

Soap, more especially soft soap, is an invaluable remedy ; it may 



398 HYPERTROPHIES. 

be used either in connection with the bath, or alone, as a discutient. 
In severe cases, the following plan may be adopted. A sufficient 
quantity is to be rubbed into the skin twice daily, for four or six 
days, during which period the patient is to refrain from bathing. 
A bath is first to be taken four or five days after the last rubbing, 
when, in fact, the epidermis has begun to peel off; afterwards 
inunction with a simple ointment is to be applied, in order to pre- 
vent Assuring of the new skin. For this purpose oil of sweet 
almond, olive oil, benzoated simple ointment, glycerine, pure or 
diluted with water, and the petroleum ointments, will be found 
the most valuable substances. 

I have found the following formula useful : 

B Adipis Benz., 51 ; 

Glycerinaj, rr^xl ; 

Ungt. Petrolei, 53s. 
M. Ft. ungt. 
Sig. — Apply daily after washing or bathing. 

Iodide of potassium in the form of ointment is also of value. 
I have used it with benefit in some cases, in the strength of from 
five to ten grains to the ounce. Milton speaks favorably of the 
following : 

R Potassii Iodidi, Qi; 
Olei Eubuli, 
Adipis, a a 5SS ; 
Glycerinae, ftji. 
M. Ft. ungt. 

In the treatment of the hvstrix variety, in addition to the 
general plan just described, it will be necessary to employ caustic 
applications, or at times even the knife, for the purpose of re- 
moving the horny patches. 

Prognosis. — This is unfavorable as regards permanent relief. 
Much, however, can be done to alleviate the condition by advice 
and appropriate external treatment; but experience teaches that 
here the value of therapeutics ceases. The deformity— for it is to 
be looked upon in this light— continues throughout life, its course 
changing but slightly, if at all, after adult age has been reached. 
The patient should always be made fully acquainted with the 
nature of the affection. 



KERATOSIS PILARIS. 399 



KERATOSIS PILARIS. 



Syn., Lichen Pilaris ; Pityriasis Pilaris. 

Keratosis pilaris is an hypertrophic affection, character- 
ized BY THE FORMATION OF PIN-HEAD SIZED, CONICAL, EPIDERMIC 
ELEVATIONS SEATED ABOUT THE APERTURES OF THE HAIR-FOLLICLES. 

Symptoms. — The disease consists essentially of an accumulation 
of epidermis about the apertures of the hair-follicles. The epi- 
thelial cells collect and heap up around the hairs, forming more 
or less conical elevations or papules. The lesions are pin-head in 
size, and are made up of epithelial structure and sebaceous matter, 
containing in their centre a convoluted or twisted hair. Each 
elevation is pierced by a hair, around which the accumulation of 
epidermis takes place concentrically, in the form of laminae. The 
hairs are either contained within the formation, and are not to be 
seen, or they protrude through the apex ; frequently they are 
broken off short at the surface, and give the papule a dark 
central point. The elevations are whitish, grayish, or blackish 
in color, and are seated upon skin which is normally colored or 
slightly reddish. The skin is always dry, rough, scaly, and harsh, 
as in ichthyosis ; passing the hand over the surface the elevations 
may be readily detected as minute, pointed asperities, feeling at 
times like a fine nutmeg grater. 

The usual seat of the affection is the extremities, particularly the 
extensor surfaces. It is ordinarily encountered about the thighs, 
and upon the arms and forearms, but it is also met with on the 
trunk. It occurs for the most part in those who are in the habit 
of not bathing ; I have, however, also observed it in those who 
used water freely. It varies in the extent of its development ; 
often it is present as so slight a disorder as almost to escape notice. 
As a rule, it is unaccompanied by itching. Its course is chronic. 

Diagnosis. — Keratosis pilaris is to be distinguished from cutis 
anserina (goose-flesh), which it may resemble, by the permanence 
of the lesions. In goose-flesh the disorder is acute, passing away 
with the exciting cause; as, for example, cold or nervous excite- 
ment. The affection may also be mistaken for the miliary papular 
syphiloderm in its desquamating stage, to which it not infrequently 
bears a close likeness. In the syphiloderm, however, the lesions 



400 HYPERTROPHIES. 

group, and are firmer, deeper seated, and less scaly. It is also 
to be diagnosed from lichen scrofulosus, in which disease the 
papules arc firmer and less scaly, and, moreover, incline to group. 
Treatment. — The treatment consists of warm or vapor baths, 
with the free use of sapo viridis, or other strong soap; alkaline 
baths are also of service. In obstinate cases oily and fatty prepa- 
rations, as, for example, glycerine, and the petroleum ointments, 
may be employed with benefit, as in ichthyosis. 

SCLERODERMA. 

Syn., Sclerema; Scleriasis ; Scleroma Adultorum ; Sclerostenosis ; Cutis 
Tensa Chronica; Dermatosclerosis ; Chorionitis ; Germ., Hautsclerem ; Fr., 
Sclereme des Adultes ; Sclerodermic 

Scleroderma is an acute or chronic disease, characterized 
by a diffuse, more or less pigmented, rigid, stiffened, or 
hardened hide-bound condition of the skin. 

The disease was first described byAlibert,* with the name of 
"scleremie des adultes." Later, Thirial recorded two cases,f 
which may be regarded as typical of the affection. As further 
illustrative of scleroderma, in contradistinction to morphoea, I 
would refer to the cases of Henke,J Bouchut,§ Rilliet,|| Gil- 
lette,! Forget,** 0'Donnell,tt Fagge,JJ Kaposi,§§ Piffard,|||| Van 

* Nosologic Naturelle, tome i. p. 498. Paris, 1817. 

f Du Sclereme chez les Adultes. Gaz. Med. de Paris, 1845, p. 523. From 
Jour, de Med. See also L' Union Medical, 1847, p. 422. 

X Handbuch zur Erkenntniss und Heilung der Kinderkrankheiten, 1809. 

I Gaz. Med. de Paris, 1847, p. 771. 

|| Eev. M6d.-Cb.ir., 1848, p. 79; also Traite Clin, et Prat, des Maladies des 
Enfants. Rilliet et Barthez, vol. ii. p. 107, 1861. 

fi Du Sclereme Simple. Arch. Gen. de Med., 1854, p. 657. 

** Gaz. de Strasbourg, No. 6, 1847 ; also Schmidt's Jahrb., lvi., pp. 184, 185. 

ff Dublin Hosp. Gaz , 1855, vol. ii. p. 6; ibid., 185G, vol. iii. p 296. 

++ Guy's Hospital Reports, 3d Ser., vol. xv., 1870, pp. 298, 299. Two cases 
are here reported, the second of which, A. D., a woman aged sixty-three, I had 
through the courtesy of Dr. Fagge the good fortune to see. The peculiarity 
in this case was the existence in front of each elbow of hard, scar-like, pig- 
mented bands of papillary hypertrophy resembling ichthyosis hystrix. Similar 
patches existed on the nape of the neck and in the axillae. 

\\ Case of Katarina Schira. Diseases of the Skin, Hebra and Kaposi. New 
Syd. Soc. Trans., London, 1874. 

Illl Case of David G. Diseases of the Skin, p. 366. New York, 1876. 



SCLERODERMA. 401 

Harlingen,* White, f Crocker,! and Madar.§ These all show 
similar symptoms, and manifestly represent the same process. Of 
the more recent cases, that reported by Dr. Van Harlingen (which 
was also under my observation) may be taken as a typical example 
of the disease, which may be described as follows. It begins by 
a more or less pronounced stiffening or hardening of the integu- 
ment, which increases in intensity rapidly or gradually until the 
part invaded becomes in most cases markedly sclerosed. As a 
rule, the process manifests itself unknown to the patient, without 
constitutional disturbance, heat, pain, swelling, or apparent altera- 
tion in the skin, the first symptom noted being a feeling of stiff- 
ness or rigidity of the integument. In other cases it is preceded 
by chills, fever, oedema, and a sense of numbness or tingling in 
the part. At other times pigmentation is the first symptom ob- 
served. The completion of the process may take place in the 
course of a few weeks or not until months or years have elapsed. 

When it is typically developed, the skin is stiff, rigid, tight, or 
immovable, and firm or even hard to the touch, imparting the 
sensation of being frozen but without the feeling of cold. It may 
also be brawny or leathery, or in more marked cases may seem 
as though wooden or petrified. The skin is bound to the tissues 
beneath, has a hide-bound feel, and is incapable of being made to 
glide over the structures beneath. It cannot be pinched up into 
folds. Sometimes the skin and subcutaneous connective tissue are 
not only firmly adherent but are bound to the fascia?, muscles, and 
bones. The skin, moreover, has a set, fixed, immobile look, owing 
to the disappearance of the wrinkles and natural lines of the part. 
Middle-aged or elderly persons are thus not infrequently made to 
appear younger. 

The infiltration passes insensibly into the healthy skin, being 
neither circumscribed nor defined by a line of demarcation. It 
is diffuse, generally occupying a considerable area of surface, as, 
for example, the neck and cheek or back ; in other cases the arms. 
Not infrequently it is more or less general. It may also spread 



* Amer. Jour, of Syph. and Derm., Oct. 1873. 
f Cases I. and II. Arch, of Derm., July, 1875. 
X Brit. Med. Jour., Dec. 21, 1878. 
\ Viertelj. fur Derm. u. Syph., Heft 2, 1878. 
26 



402 HYPERTROPHIES. 

out in the form of small or large, irregularly-shaped, ill-defined 
patches, or it may, more rarely, show itself in the form of narrow 
or broad bands, as, for example, down the limbs or across the 
mamma, in which event the process resembles morphoea. It is 
in these cases that the line separating the two diseases becomes 
ill defined, morphoea seeming to be superadded to scleroderma. 
The affected surface, as a rule, is neither elevated above the level 
of the surrounding skin nor depressed below it; exceptions to this 
statement would be found in the case of oedema, or of band-like 
formations, and in the later atrophic stages of the disease. The 
surface, moreover, is generally even and smooth, shining or velvety ; 
but at times it shows a dry, more or less desquamating, shrivelled 
epidermis; in other instances, usually in connection with localized 
areas which may occur here and there, slight or extensive papillary 
hypertrophy, resembling ichthyosis, may be present. Pigmenta- 
tion generally exists, which may be yellowish or brownish, in the 
form either of a discoloration or of irregularly shaped and sized 
spots and patches, giving a mottled or speckled appearance. Some- 
times the skin is paler than normal, from tension, and has a 
stretched, whitish or yellowish, waxy look. The temperature is 
either normal or slightly diminished. The subjective symptoms 
are not constant. Occasionally there is numbness, pain, tingling, 
or itching, while at times deep-seated neuralgic or cramp-like 
pains, especially in the limbs, are complained of. In all cases 
there is a feeling of contraction of the skin, of its being tight or 
stretched or too short. 

The disease may attack any region; but it is most frequently 
encountered about the neck, where it often begins, shoulders, back, 
chest, arms, and face. It may be universal, as in Schwimmer's 
case.* Occurring over the face, the countenance becomes changed 
and assumes an expressionless, immobile, fixed, inanimate, staring, 
grinning, or anxious look. Attacking the hands, the fingers be- 
come semi-flexed, rigid, and immovable. Thus the patient may 
be rendered helpless. The disease is usually symmetrical. Both 
sides of the trunk, and both extremities, are generally invaded, 
though not always in precisely the same region. The invasion 
may be sudden or gradual, the latter being the more usual course. 



■ Abstract in Lond. Med. Record, March 15, 



SCLERODERMA. 403 

The evolution of the disease is variable. It may be acute, as in 
the cases of Piffard and Crocker, or, as is the rule, chronic. Weeks 
or months may elapse before the sclerosis reaches its height, when 
the condition may remain in this state for months or years or may 
shortly undergo spontaneous involution, this change taking place 
usually very gradually, leaving the skin normal. On the other 
hand, atrophic symptoms may succeed the sclerosis, characterized 
by a shrinking or contraction with condensation of the tissues, 
with loss of subcutaneous fat, the integument seeming to be bound 
to the bones. Over the joints the skin may become so fixed and 
immobile that excoriations and ulcers may result. About the face, 
too, the integument may become so bound that motion may be in- 
terfered with; and in one case reported by Dr. Fagge the disease 
was so pronounced about the jaws and mouth that the patient suc- 
cumbed from exhaustion and starvation through inability to eat. 

The general health, as a rule, is good, being unaffected by the 
disease. In some cases rheumatism and neuralgic pains have been 
noted. Difficulty in respiration, from the bound, contracted state 
of the integument over the thorax, has also in some instances 
existed. The sudoriparous and sebaceous glands are usually un- 
affected, except where the sclerosis is very marked, when it may 
be diminished. Other cutaneous diseases may appear upon sclero- 
dermic skin, as, for example, erysipelas, eczema, herpes zoster, 
variola, and acne. Patches and other less pronounced manifesta- 
tions of morphoea may accompany the disease, as in the case 
of Mrs. M., reported by Hutchinson,* and in that of Elizabeth 
Nicholls,f recorded by Fagge; and indeed the coexistence of 
certain symptoms common to either affection is not rare. In 
the case of Elizabeth JNTicholIs true keloid was also present and 
added to the complication. 

Etiology. — The cause of the disease is exceedingly obscure. An 
examination of the recorded cases throws but little light on the 
subject. It may occur at any period of life, but is of most fre- 
quent occurrence in early adult and middle age. It is met with 
far oftener in women than in men. In an analysis of twenty-eight 



* Lectures on Clinical Surgery, vol. i., Part II., p. 340. London, 1879. 
f Guy's Hospital Reports, 1867 ; also Catalogue of New Syd. Soc, Atlas of 
Skin Diseases, Part II., London, 1875, reported by Mr. Hutchinson. 



404 HYPERTROPHIES. 

cases, Van Harlingen cites twenty females and only eight males. 
Rheumatism, especially of the joints, has been noted to precede 
the attack in many cases. Exposure to wet and to cold, or sudden 
changes of temperature, have even oftener been referred to as the 
exciting cause. Violent impressions on the nervous system have 
also been spoken of. The general health, as stated, is usually 
good, and often remains so throughout the course of the disease. 
In cases where death has occurred it lias been from some inter- 
current malady. The disease is exceedingly rare.* The statistics 
of the American Dermatol ogical Association record but two cases 
among 16,863 cases of skin disease. My own experience is limited 
to a few cases. 

Pathology. — Concerning the nature of the disease, its place in 
classification, and its relations to other diseases, especially morphoea, 
much has been written, but the views of authors differ to such an 
extent that at present little can be positively stated. By many 
dermatologists scleroderma and morphoea arc regarded as merely 
different manifestations of the same disease, a conclusion which 
was first arrived at by Fagge in 1867 in an able analytical article, 
and which has been adopted by others in England, in Germany, 
and in this country. The fact that the two diseases are very 
closely allied in their nature, as well as in the form of some of 
their cutaneous manifestations ; that certain of the symptoms 
usually present are common to both affections; and, finally, that 
these manifestations may occur, either simultaneously or at dif- 
ferent periods in the course of the disease, upon the same patient, 
admits of no question. The difficulty of deciding upon the dif- 
ference or the identity of the two forms of disease arises from the 
fact that both are capable of assuming a variety of forms, and 
that these forms present entirely different clinical features as they 
are seen at one or another stage. This is particularly true of the 
process I have described as morphoea; and it is chiefly for this 
reason that for the present I deem it advisable to consider them 
separately. Very rarely marked expressions of both forms of 

* Cases have also been reported by Arnold. Amer. Jour, of the Med. Sci., 
July. 1869; Day. Amer. Jour, of the Med. Sci.. April, 1870; Piffard. New 
York Med. Gaz., June 24, 1871 ; Yan Harlingen (with a bibliography), Amer. 
Jour, of Syph. and Derm., Oct. 1873; and White, Arch, of Derm., July, 
1875. 



SCLERODERMA. 405 

disease are encountered on the same subject, as has been already- 
stated, but, as a rule, we meet with one or the other. More fre- 
quently it is rnorphoea, though not in the restricted sense which 
has been given the name by some writers. I have seen but few 
well-marked examples of scleroderma, but as many as twelve or 
fifteen cases of rnorphoea, in none of which did there exist the 
symptoms which I have described as characteristic of scleroderma. 
It is therefore evident that a name should be given to represent 
these important changes in the skin which differ in so many symp- 
toms from typical scleroderma.* The anatomy of scleroderma has 
been studied by Forster,f Auspitz,J Arning,§ Neurnann,|| Fagge,f 
Kaposi,** Chiari,tt and others, with somewhat varying results, 
doubtless due to the fact that the cases represented different stages 
of the disease. Sections have been taken from the living subject 
as well as from the cadaver. It is noteworthy that, notwith- 
standing the marked clinical features of the disease, but little 
deviation from healthy integument has been demonstrated. The 
following, however, will represent the changes usually found. The 
epidermis remains unaltered in structure, but contains a deposit of 
pigment in the lower layers of the rete and in the papillary layer 
of the corium. The papillae are normal in size, except where 
manifest papillary hypertrophy exists, as, for example, in the case 
of roughened bands or patches. Both the corium and the sub- 
cutaneous tissue are the seat of the disease. They are found to 
be thickened, and to contain a marked increase of the connective 
tissue with condensation and elastic fibres. In the subcutaneous 
tissue the fat cells are scanty, and are surrounded by dense bundles 
of connective tissue. The whole cutaneous tissue is thus con- 



* Fagge and others have proposed to designate both forms of disease as 
scleroderma, and that two varieties, namely, " diffused" and " circumscribed," 
be made. The objection to this nomenclature would be that rnorphoea is, as 
I have shown, far from being in all cases circumscribed. 

f Wiirzburger Med. Zeitschr.. 1861, Bd. ii. p. 294. 

J Wiener Med. "Wochenschr., 1863 ; quoted in Neumann's work, 3d edit. 
(German), p. 354. 

\ Wiirzburger Med. Zeitschr., 1861, vol. ii. p. 186. 

|| Loc. cit., 3d edit. (German), p. 354. 

f Lond. Path. Soc. Trans., 1871. 

** Loc. cit., vol. iii. p. 119. 

ff Viertelj. fur Derm, und Syph., Heft 2, 1878. 



406 HYPERTROPHIES. 

verted into a compact mass, made up of densely-packed fibres 
more or less interlaced and bound together. Concerning the ves- 
sels, Kaposi states that he found them "diminished in calibre, and 
closely surrounded by connective tissue. In spots here and there, 
and in large tracts, the connective tissue surrounding both sides 
of a vessel appeared pushed aside from its walls by small, nucle- 
ated (lymph) cells closely heaped on one another. Bv these cell- 
masses the vessel was increased to five or six times its normal 
breadth, as if enclosed in a cell-sheath." The same observer has 
expressed the view that the disease is due to a thickening and stasis 
of lymph, in consequence of an abnormal state of the nutritive 
processes, the stagnation occurring in the lymph spaces. Chiari in 
an examination of a marked case found the spinal cord and ganglia 
healthy. The sweat and sebaceous glands and the smooth mus- 
cular tissue are said to remain normal. Madar* is of the opinion 
that the disease is a central trophoneurosis. For the present it 
may, I think, be regarded primarily as a form of hypertrophy, 
due probably to some obscure nervous disturbance, followed sooner 
or later by resolution or by more or less atrophy. 

Diagnosis.— Bearing in mind the peculiar characters of the 
disease, which are in most cases well marked, no difficulty should 
be experienced in determining the diagnosis. The solidified, rigid, 
hard, more or less pigmented condition of the integument, in its 
early stages, apparently unaltered in structure, will alone be suf- 
ficient to distinguish it from other diseases. From morphcea, to 
which, as already stated, it is closely allied, both in nature and in 
some of its clinical features, it may be distinguished bv the follow- 
ing points. Scleroderma is disposed to involve large areas of sur- 
face, either in the beginning or during its course, as, for example, 
the greater portion of the trunk ; morphcea usually appears as one 
or more small areas, often not larger than coins. Scleroderma 
is always diffused or spread out, and is unattended by any line of 
demarcation; it may be universal. Morphcea, when in patches, 
is circumscribed and surrounded by a sharp line of demarcation 
and a pinkish or lilac border fading into the healthy skin. Scle- 
roderma is always characterized by a variable degree of stiffness 
or hardness and rigidity; morphcea is usually soft or firm, but is 



* Yiertelj. fur Derm, und Syph., Heft 2, 1878. 



SCLERODERMA. 407 

seldom hard. In scleroderma the skin in many cases does not 
appear altered in structure, usually resembling stiffened or frozen 
normal integument; in morphoea there is always perceptible and 
generally marked change in the structure of the skin. In sclero- 
derma the disease begins by a simple stiffening or hardening of 
the integument; in morphoea it begins by the formation of a more 
or less distinct hypersemic, reddish, or violaceous soft patch, which 
only later assumes the more characteristic appearance. Sclero- 
derma generally manifests itself insidiously and without subjective 
symptoms; morphoea is often accompanied by pain or tingling. 
Scleroderma is generally more or less symmetrical; it seldom 
appears over definite nerve tracts ; morphoea is usually asym- 
metrical, and is often met with over nerve tracts. Scleroderma 
does not show the enlarged, superficial, bluish bloodvessels or the 
stria? atrophica? of morphoea. Scleroderma often manifests itself 
acutely ; morphoea is usually slow in its development, months and 
years being sometimes occupied in the formation of the lesions. 

Treatment. — Various plans of treatment have in different cases 
been instituted, under some of which the patients have improved, 
but it was doubtful whether the cure was to be attributed to the 
remedies or to the spontaneous involution of the process. Con- 
stitutional remedies, such as arsenic, quinine, and cod-liver oil, 
together with the employment of inunctions, baths, massage, and 
stimulating frictions, in the form of liniments and ointments, as, 
for example, mercurial ointment, offer the most hope. The con- 
stant electric current, as recommended by Fieber* and Piffard,f 
may also be employed with the expectation of benefit. Ar- 
maingaudj and Schwimmer§ also report cases improved by the 
galvanic current. 

Prognosis. — The course and termination of the disease will be 
found to vary. The prognosis should be guarded. Not infre- 
quently the condition undergoes involution to recovery, while in 
other instances the symptoms remain persistently throughout life. 
Contraction and immobility of the parts may occur, attended by 
more or less deformity and suffering. 

* Wiener Med. Wochenschr., Nov. 26, 1870. f Loc. cit. 

J Sur un cas de sclerodermic, etc. Paris, 1878. 

I Pest. Med.-Chir. Presse, No. 23, 1879. Abstract in Lond. Med. Record, 
March 15, 1880. 



408 



HYPERTROPHIES. 



MORPHEA. 



Symptoms.— The disease,* formerly known as the " keloid of 
Addison," is characterized by a variety of lesions which incline to 
undergo important changes in the course of their evolution. It is 
only by familiarity with these numerous phases of the disease that 
an idea of the whole process can be obtained. It may appear in 
one of several ways. Frequently it begins by the development of 
one, two, or more isolated, round, ovalish, or irregularly rounded 
or elongate, pinkish or purplish, hypersemic patches, the size of a 
small or large coin. They soon become well denned and circum- 
scribed, and surrounded by a faint or distinct pinkish, violet, or 
lilac border or areola, several lines in width, made up of very 
minute capillaries. 

The patch in its early stage may be slightly puffed or elevated, 
but as generally seen iu a later stage it is on a level with the sur- 
rounding skin, or, still later, even slightly depressed. When fully 
developed, it is usually firm to the touch, but not hard, while, on 
the other hand, not infrequently it is soft and feels but little dif- 
ferent from the neighboring healthy skin. In other cases it has 
a somewhat tough, leathery, or brawny feel, and can only with 
difficulty be pinched up between the fingers. The sensibility at 
this stage generally remains unimpaired. The surface is usually 
smooth and shining, and sometimes has a polished, ivory look; in 
other cases, where the lesion is old, it is covered with more or less 
scanty, dry, adherent, shrivelled epidermis. In color the patch is 
pale-pinkish or violaceous, light-yellowish, or even whitish, and 
waxy, resembling in these cases a section of bacon which has been 
cut and laid into the skin, giving it a lardaceous appearance. Iu 
some cases it has an ivory look. In the early stage minute plex- 
uses of bloodvessels may sometimes be detected ramifying over 
the surface. Around the patches there is almost always more or less 
yellowish or brownish mottled pigmentation of a diffuse character. 



* I include under the term morphcea two forms of disease heretofore con- 
sidered by writers under the names "keloid of Addison" and "morphoea," 
believing that they are but different manifestations of the same process. 
The so-called " morphreaof leprosy," although sometimes resembling the dis- 
ease under consideration, is but one of the many cutaneous symptoms of that 
disease, and is in no way connected with the affection about to be described. 



MOEPHCEA. 409 

The lesions manifest themselves upon various regions, showing 
preference for the face, neck, chest, mammae, back, abdomen, arms, 
and thighs. They exhibit no disposition to symmetry. They are 
not infrequently encountered along nerve tracts, as, for example, 
over the distribution of the fifth pair. The secretion of sweat 
is diminished or absent, according to the extent of the atrophic 
changes in the lesions. 

Their course is variable, though almost always chronic. They 
usually appear insidiously, or, as sometimes happens, are preceded 
by pain or tingling, and increase in size slowly and gradually until 
they become as large as a silver coin or even as large as a hand. 
Occasionally two neighboring patches will coalesce. As a rule, they 
are not accompanied by marked subjective symptoms, but sometimes 
itching and tingling or numbness, in other cases pain, are present. 

Having reached their definite proportions, they either remain 
in this state for months or years or begin at once to undergo 
spontaneous involution, which sometimes takes place with rapidity, 
leaving the integument healthy. In other cases they tend to un- 
dergo atrophic changes, the skin becoming contracted, thin, parch- 
ment-like, or shrivelled, and, later, bound to the tissues beneath, 
forming large or small, rounded or elongate cicatriform lesions, 
causing contraction and disfigurement. The subcutaneous and 
even muscular tissues may become wasted and shrunken, giving 
rise to deformity and, in the case of a limb, to loss of power. 

In place of the macules, or patches, just described, the disease 
may manifest itself by lesions of a more distinctly atrophic char- 
acter, consisting of aggregated or disseminated, small, funnel- 
shaped or pit-like depressions in the skin, resembling the scars of 
acne atrophica; reddish, bluish, or purplish, more or less tortuous, 
short or long, dilated bloodvessels; and whitish, pearly, smooth, 
glazed, slightly depressed macules and grooved streaks (maculae 
et striae atrophica?). Here and there, either alone or in connection 
with these features, variously sized, reddish or purplish, telangiec- 
tatic, more or less slightly pigmented, diffuse, soft, normal-feeling 
patches, surrounded by yellowish or brownish pigmentation, may 
develop, which may sooner or later undergo spontaneous involu- 
tion, or, on the other hand, may pass into the further advanced 
characteristic, circumscribed, yellowish, lardaceous-looking or ala- 
baster-like lesions. 



410 HYPERTROPHIES. 

It will thus be seen that the process is an exceedingly complex 
and an unusually variable one, characterized by a variety of lesions, 
all or only some of which may be present in a given case. As a 
complication, true keloid (the keloid of Alibert) may also be pres- 
ent, as in the rare case of Elizabeth Nicholls and in one reported 
by Mr. Hutchinson.* 

Its course is chronic, but it inclines, except in the severer 
forms, to recovery. Years may elapse in some cases before decided 
changes occur, while in some instances it increases in severity from 
year to year, ending in great deformity. The disease is rare, but 
not so rare as scleroderma, f The statistics of the American Der- 
matological Association record but a single case among 1G,863 
cases of skin disease. But it is commoner than these figures imply. 

As typical examples of the disease, I would refer to the cases of 
Addison,! Wilson,§ Bulkley,|| Morrow,! Gibney,** Graham,tt 
Robinson,! J and Abbe.§§ Well-marked examples are also re- 
corded by IIutchinson.|||| 

Etiology. — Nothing positive is known of the cause of the dis- 
ease, although, as in scleroderma, the nervous system is doubtless 
the primary seat of disorder. In corroboration of this statement 
the simultaneous occurrence of markedly neurotic diseases, as 
canities and alopecia areata, may be referred to. It occurs far 
more frequently in women than in men. Of the numerous cases 
that I have seen, almost all have occurred in females. It is en- 
countered in the strong as well as in the weakly, and at all ages! 

* Loc. cit., p. 329. t See Scleroderma. 

X A Collection of the Published Writings of the late Thomas Addison. New 
Syd. Soe , London, 1809. Cases III. (E. W.) and IV. (L. B.). See also an 
account of these cases in Fagge's article on the keloid of Addison, Guy's 
Hospital Reports, I 

I Diseases of the Skin, London, 1867, p. G75 ; see also an article in the Jour, 
of Cut. Med., vol. ii. Xo. 6. 

|| Arch, of Derm., Jan. 1877. Case I. (B. M.) ; Case II. (Ann B.). Also 
Arch, of Derm., Jan. 1879 (Case of Bessie Lindsey), and April, 1880. 

1 Ibid., April, 1879. Case of Mary Marshall. 

** Ibid. Case of Alice Dowling. 

ft Ibid., April, 1880. This case was also under my observation, and is the 
counterpart of several other cases under my care. 

XX Arch, of Derm., April, 1880. \\ Ibid. 

||l| On Morphcea. Lectures on Clinical Surgery, vol. i., Part II. London, 
1879. 



MOEPHCEA. 411 

Pathology. — The pathology of the disease is obscure. Concern- 
ing the relations of morphoea to scleroderma, the reader is referred 
to the chapter on the latter disease. For the present it may be 
stated that these two forms of disease, while closely related both in 
their symptomatology and in their pathology, are worthy of being 
distinguished and considered separately. Wilson,* Hutchinson, f 
and Crocker J have called attention to the not infrequent occur- 
rence of the disease over the course of known nerve tracts ; but, 
while this observation is true of certain cases, many examples 
might be cited where such is not the case. Hutchinson in par- 
ticular insists upon its neurotic origin, a view which is, in my 
opinion, not invalidated by the appearance of the lesions remote 
from the course of large nerves. I entirely agree with those 
who hold the nervous system at fault, and have for some time 
regarded the disease as a trophoneurosis. 

The pathological anatomy of the characteristic patches, or 
plaques, of morphcea varies considerably with the stage in which 
the disease is examined. In a soft, pliable, whitish pa,tch, of some 
months' duration, taken from the back, the most marked altera- 
tion that I could discover was a condensation of the connective 
tissue of the corium, with a shrinkage of the papillary layer. 

Crocker examined whitish patches in their early stage, and 
reports partial disintegration in the deeper layers of the epidermis ; 
atrophy of the papillary layer; thrombosis of the longitudinal 
vessels in the superficial plexus; and abundant cell infiltration 
around the sebaceous glands, hair-follicles, and vessels. In the 
later stages he notes the development of these cells into fibrillar 
tissue ; its contraction, and the consequent obliteration of blood- 
vessels, and atrophy of the sebaceous and sweat glands. 

Diagnosis. — The relationship between the conditions designated 
in literature by the names , morphcea, keloid of Addison, sclero- 
derma, and striae et maculae atrophica?, is variously interpreted by 
observers. The following points of difference may be mentioned. 
Morphoea differs from scleroderma in that its lesions are more 
or less circumscribed; this is particularly the case in the macular 
form of the disease, where the patches exist as well-defined, cir- 

* Loc. cit. f Loc. cit. 

X Lancet, Nov. 22, 1879. The case reported showed the lesions strikingly 
distributed alone; the track of nerves on the arm and forearm. 



4 1 2 HYPERTROPHIES. 

cumscribed, yellowish, fatty-looking, soft or firm patches. It 
also differs from scleroderma in the absence of the peculiar sclero- 
dermic hardness. In the later stages of morphcea, where distinct 
atrophy and cicatrization have occurred, the condition will scarcely 
be confounded with scleroderma. Other symptoms of a different 
nature, as, for example, pigmentation and cicatrization, will usually 
be present'in the later stages of morphcea, whereby the conditions 
may be separated. (See Scleroderma.) The atrophic stria; of mor- 
phcea, as seen in one form of the affection, are with difficulty to 
be distinguished from the linese albicantes so often seen upon the 
abdomen. 

The roundish, circumscribed patches of morphcea bear a strong 
resemblance to the anaesthetic spots of leprosy. In general ap- 
pearance these two forms of disease possess many features in 
common ; and it is probable that they are both due to the same 
cause, namely, perverted innervation, the nerves being, as is well 
known, markedly involved in leprosy, while iu morphcea the 
existence of some trophoneurosis is more than likely. The red- 
dish or yellowish patches or macules of leprosy are well-known 
symptoms common to both the tubercular and the anaesthetic 
variety of the disease. When fully developed, they are always 
anaesthetic, and are usually accompanied by other symptoms of 
leprosy. 

The whitish patches of morphoea bear some likeness to vitiligo; 
but in vitiligo the disease is one affecting the pigmentary layer 
only, the texture of the skin itself being in every respect normal, 
and hence could not be confounded with the structural change in 
the skin which takes place in morphcea. 

Treatment. — A general tonic treatment is called for, consisting 
of the liberal use of cod-liver oil, the preparations of iron, and 
especially arsenic. The last-named remedy, continued for a long 
period, possesses, I think, positive value. More benefit probably 
is to be derived from its judicious use than from any other reined v. 
Where it is to be used for months it is of importance to begin with 
small doses, gradually increasing the quantity until the patient 
takes as much as possible without disturbing the general health. 
The constant galvanic current may also prove of service, and is 
worthy of an extended trial. I have seen cases where it seemed 
to benefit the patient decidedly. 



MOEPHCEA. 413 

Prognosis. — It is a chronic form of disease, undergoing very 
slow and gradual evolution, and may continue throughout life. 
Sometimes, however, it runs a comparatively short course, com- 
prising months rather than years. In mild forms it inclines sooner 
or later to spontaneous recovery, and in some cases this occurs 
most unexpectedly. Where extensive atrophy has already taken 
place, complete restoration cannot be looked for. 

As closely allied to morphoea or as a variety of this disease, I 
would also include many, if not all, of the cases of the disease 
known in literature as hemiatrophia facialis, or unilateral 
atrophy op the face. The disease here consists in a variable 
degree of atrophy of a portion or of the whole of one side of the 
face, involving the skin, subcutaneous connective tissue, and deeper 
structures, including in some cases the bones. The origin of the 
disease is of course deeper-seated than in morphoea. The changes 
which take place in the skin are in my opinion of the same nature 
as those which occur in the characteristic lesions of morphoea 
met with in other regions. The disease has been observed with 
marked morphoea upon other regions, as in Gibney's case.* In 
the several cases which I have seen I have not been able to detect 
any essential difference. The neurotic origin here is manifest, so 
evident, indeed, that this form of the disease has received atten- 
tion chiefly at the hands of neurologists. Among those who have 
written on the subject, Parry,! Romberg,! Moore,§ Lande,|| 
Eulenburg,^" Fremy,** Hammond,ff Bannister, J J and Robin- 
son §§ may be mentioned. 

* Loc. cit. 

f Quoted by Eomberg in Lehrb. der Nervenkr des Menscben. Berlin, 1854. 

X Trophoneurosis Facialis, Klinische Wahrnehmungen und Beobaeh- 
tungen. Berlin, 1851. 

g Unilateral atrophy of the face. Dublin Quar. Jour, of Med. Sci., 1852. 

|| Essai sur l'aplaise lamineuse progressive. Paris, 1868. 

^[ Lehrbuch der functionellen Nervenkrankheiten. Berlin, 1871. 

** Etude critique de la trophonevrose faciale. Paris, 1872. 

ff Progressive Facial Atrophy. A Treatise on Diseases of the Nervous 
System, 6th ed., New York, 1876. Also Journal of Nervous and Mental 
Diseases, April, 1880. 

XX Progressive Facial Hemiatrophy. Ibid., Oct. 1876. 

\\ A case of unilateral atrophy of the face, etc. Amer. Jour, of the Med. 
Sci., Oct. 1878. 



414 HYPERTROPHIES. 



SCLEREMA NEONATORUM. 



Syn., Scleroderma Neonatorum; Induratio Tela3 Cellulosas Neonatorum; 
Algor Progressivus ; Sclerema of the Newborn; Germ., Das Sclerem der 
Neugeborenen ; Zellgewebsverhartung der Neugeborenen ; Die Greisen- 
haftigkeit der Kinder ; F/\, Algidite Progressive ; Decrepitude Infantile. 

Sclerema neonatorum is a disease of infancy, appearing 

USUALLY AT BIRTH, CONSISTING OF A DIFFUSED STIFFNESS AND HARD- 
NESS OF THE CUTANEOUS AND SUBCUTANEOUS TISSUES, ACCOMPANIED 
BY COLDNESS, (EDEMA, SWELLING, DISCOLORATION, LIVIDITY, AND 
GENERAL CIRCULATORY DISTURBANCE. 

Symptoms. — The disease may be congenital or may appear 
during- early infancy. It usually begins in the lower extremities, 
and extends upwards, involving the trunk, arms, and face. The 
skin frequently assumes a glossy, reddish, or purplish hue; in 
other cases it is yellowish, or even brownish. A mottled aspect, 
more or less marked, may be present. The integument appears 
stretched and tense. To the touch it offers a remarkable and 
striking induration, being firm, hard, rigid, and incapable of being 
taken up between the fingers. The amount of hardness varies in 
places, but is generally most marked about the legs. The surface 
is cold, especially about the extremities. Upon pressure there is 
more or less oedema, together with an infiltrated, thickened condi- 
tion of the tissues. On account of the rigidity of the parts, mo- 
tion is interfered with. When the disease is generalized, the -kin 
possesses a resemblance to that of a half-frozen corpse, as regards 
both its appearance and its feel. The child is unable to move, 
takes but little nourishment, respires feebly, and usually sinks 
and dies in a few days. Very rarely, spontaneous recovery takes 
place. The disease is usually found associated with pneumonia 
or other affections of the respiratory system, or with diseases of 
the circulatory system. 

Etiology. — The causes are unusually obscure. It has been 
observed to occur most frequently in premature children. The 
capillary circulation is manifestly at fault; but whether this is 
the primary difficulty, or is secondary and dependent upon the 
structural change in the tissues, remains undetermined. 

Pathology. — After death the skin is observed to undergo but 
little change; the coloring of the skin usually becomes more in- 



ELEPHANTIASIS. 415 

tense. The induration remains. Upon incision, a large quantity 
of yellowish, serous fluid is poured forth, after which the structures 
become softer and resemble ordinary oedematous tissue. The sub- 
cutaneous tissue is noted to contain a firm, stearine-like deposit. 
Microscopic examinations have been made by Virchow,* Forster,f 
L5schner,J Jenks,§ and others, with somewhat unsatisfactory re- 
sults. Considerable oedematous infiltration exists throughout the 
tissues. The connective tissue of the corium is greatly increased, 
according to Loschner and Jenks ; other observers, however, have 
not been able to determine this point. The stearine-like deposit 
is noted to occupy a large tract in the subcutaneous layers. 

Diagnosis. — The features of the disease are so well marked as 
to cause no difficulty in its recognition. The induration, oedema, 
and peculiar color of the skin, the coldness of the surface, the im- 
paired circulation and respiration, all point unmistakably to this 
disease. It differs from the scleroderma of adults in the nature 
of the cutaneous deposit, as well as in its history and its course. 

Treatment. — This should be directed against the general condi- 
tion. Cutaneous stimulation, gentle frictions, warmth, and other 
like measures are to be resorted to and persevered in. The prog- 
nosis is very unfavorable. 

ELEPHANTIASIS. 

Syn., Elephantiasis Arabum ; Pachydermia; Bucnemia Tropica; Morbus 
Elephas ; Elephant Leg ; Barbadoes Leg ; Spargosis. 

Elephantiasis is a chronic, hypertrophic disease op the 
skin and subcutaneous connective tissue, characterized by 
enlargement and deformity of the part affected, accom- 
panied by lymphangitis, swelling, cedema, thickening, indu- 
ration, pigmentation, and papillary growth. 

Symptoms. — The affection usually begins by an inflammation 
of an erysipelatous nature, attended by general febrile symp- 
toms, pain, heat, lymphangitis, swelling, oedema, and sometimes 
discharge, followed by slight permanent enlargement of the part. 

* Die Krankhaften Geschwiilste, Bd. i. p. 302. 

t Path. Anat., Bd. ii. p. 1070, Zvveite Auflage. Leipzig, 1863. 

X Prager Viertelj., 1868. 

\ Amer. Jour, of Obst., May, 1871, p 129. 



416 HYPERTROPHIES. 

Attacks of this description recur from time to time, the limb or 
region involved being, as a rule, slightly increased in size upon 
each occasion. After a year or longer, during which period a 
number of attacks will probably have taken place, the part will 
in most cases be seen to have attained considerable size, to be 
chronically swollen and cedematous, and to be quite hard ; and 
not only the leg but the skin itself to be generally hypertrophied, 
as shown by induration, enlarged and prominent papillae, fissures, 
and more or less discoloration and pigmentation. The process 
rarely ceases until the part has enlarged to such an extent as to be 
attended by deformity. 

The disease appears somewhat differently as one part or another 
of the body is affected. The common seat of the disease is the 
lower extremities, especially the legs. One limb only, however, is 
ordinarily attacked, the disease seldom showing itself symmetri- 
cally. The genitalia are the regions next attacked in point of fre- 
quency, the penis, scrotum, labia, and clitoris being all liable to 
invasion. Other regions are more rarely assailed, although cases 
are recorded in which the face, arms, and breasts have been 
involved. 

The leg being the usual seat of the disease, a description of the 
appearances as ordinarily seen here may be given. After the affec- 
tion has existed for some time, and as observed in a quiescent state 
between the inflammatory attacks, the leg will usually appear hy- 
pertrophied, the enlargement beginning generally below the knee 
and extending down to the ankle, the foot being more rarely in- 
volved. The limb is swollen, the tissues pitting upon pressure 
and exhibiting signs of general thickening and induration, and 
is usually considerably deformed. The skin is hypertrophied in 
all its parts. It may be either smooth or rough ; when smooth, 
eczema is not infrequently present, and is a complication. Papil- 
lary hypertrophy, in the form of wart-like prominences, is apt to 
develop, especially over the region of the foot and the toes. Fis- 
sures are also met with, while the normal lines and folds of the 
surface are all exaggerated. Maceration of the epidermis, together 
with accumulation of extraneous matter, generally occurs about 
these folds, giving rise to offensive masses of decomposition. 
Scales and crusts are generally present, the latter being formed 
by the discharge, together with the blood and sebaceous matter, 



ELEPHANTIASIS. 417 

which oozes from between the warty formations. Ulcers are at 
times developed from varicose veins which may exist. More or 
less discoloration and pigmentation, giving the limb a reddish or 
brownish aspect, also take place. The amount of pain attending 
the disease varies ; at times it is violent, especially during the 
inflammatory attacks, while in other cases but little discomfort is 
experienced. The weight of an affected part, as a limb or the 
scrotum, is always appreciable, and may be so great as to inca- 
pacitate the individual from walking. Where there is a tendency 
to eczema, itching may be an annoying symptom. The course of 
the affection is emphatically chronic. 

Etiology. — Elephantiasis is found in all parts of the world, but 
is of much more frequent occurrence in some countries than in 
others. It is endemic and especially common in tropical climates ; 
Barbadoes, and the other islands of the West Indies, South America, 
India, the Malayan Peninsula, China, Japan, Egypt, Arabia, and 
Africa may be mentioned as affording by far the greatest number 
of cases. Instances are also encountered throughout Europe and 
our own country, irrespective of latitude or place. The disease 
where endemic occurs chiefly in low, malarial districts, upon islands, 
and along the sea-coast. Climatic conditions, it would appear from 
this statement, must be held accountable for a certain amount of 
influence in its development. It is, however, not improbable that 
the want of proper hygienic measures, depraved habits, and bad 
food also play a prominent part in the production of the disease, 
for the vitiated condition of the inhabitants of tropical countries is 
well known. It is due to inflammation and obstruction of the lym- 
phatics, although the cause of the disturbance is obscure. Accord- 
ing to the observations of Lewis, Manson, and Bancroft,* con- 
ducted in India, China, and Australia, the presence of filarise in 
the blood and lymphatics is thought to be largely concerned in the 
causation of the disease in Eastern countries. It has been shown 
that the parasite is at least very frequently present. Certain 
filarise have unquestionably been found in the blood and lymph in 
cases of enlargement of the scrotum — so-called "lymph-scrotum" 
— with chylous exudation, and also in cases of elephantiasis asso- 



, * See an interesting article by Fayrer on the relation of filaria sanguinis 
hominis to the endemic diseases of India. Lancet, Feb. 8 and 15, 1879. 

27 



418 HYPERTROPHIES. 

dated with lymph-scrotum.* The question of the identity of these 
diseases, however, is a subject of dispute. Manson f brings for- 
ward cases to prove that they are identical. The same author is 
moreover of the opinion that the mosquito is instrumental in 
propagating the filarial, and consequently the disease. It has been 
noted that the affection is one confiued in a great measure to the 
poor and improperly cared-for, the well-to-do being seldom at- 
tacked. It is met with in both sexes, but is more common in males. 
It rarely appears before puberty. It is neither hereditary nor con- 
tagious. The subject of congenital elephantiasis, cases of which are 
sometimes encountered, has received attention from Busey.^ 

Pathology. — The anatomy of the disease has been studied by 
Virchow,§ Kaposi, || and others. The tissues, when cut into with 
a knife, are found to be firm, and show a whitish or yellowish 
surface. When pressed upon, they give forth a yellowish fluid. 
The bulk of the growth is made up of hypertrophic connective 
tissue, having its seat for the most part in the subcutaneous con- 
nective tissue; the corium is likewise hypertrophied, although 
proportionately to a much less extent. The mass is composed of 
bundles of stout fibres, running in various directions, forming a 
dense net-work, together with smaller fibres and nucleated cells. 
The corium and epidermis vary in thickness and structure, accord- 
ing as the surface of the growth is smooth or covered with papil- 
lary elevations. These latter are often greatly developed, forming 
warty growths, and are composed of elongated papillae, either with 
or without epidermic covering, according to their situation. The 
bloodvessels of the diseased tissue are found much enlarged. The 
lymphatics are, in like manner, greatly increased in calibre. When 
the disease has continued for some time, various changes may take 
place in the deeper parts of the structure, among which may be 
mentioned fatty degeneration and atrophy of the muscles, and 
thickening of the bones accompanied by exostoses. 

* See " Observations on Lymph-Scrotum and Allied Diseases," by Patrick 
Manson, in Med. Times and Gaz., Nov. 13 and 20, 1875. 

f Additional Xotes on Filariu Sanguinis Hominis and Filaria Disease. Sec 
Customs Medical Eeports, xiii. 30 ; xiv. 1. Shanghai. (Keprint.) 

X Congenital Occlusion and Dilatation of Lymph Channels. New York, 
1878. 

I Die Krankhaften Geschwulste, Band i. p. 308. 
Loc. cit., vol. iii. p. 140. 



ELEPHANTIASIS. 419 

Diagnosis. — After enlargement has begun to take place, no dif- 
ficulty can arise as to the diagnosis. The peculiar erysipelatous 
inflammation, together with the part attacked, also points to the 
disease. Recurrent attacks of erysipelas about a limb should 
always be regarded as indicative of a probable increase in the 
connective tissue. It need scarcely be mentioned that no connec- 
tion exists between the disease under consideration and lepra, or 
leprosy. At the same time they may coexist, as has been shown 
by Vincent Richards.* 

Treatment. — During an inflammatory attack the part should be 
treated by absolute rest, and cold or hot applications. After the 
pain and heat have subsided, the limb may be rubbed with one of 
the mercurial ointments and encased in a well and closely applied 
bandage. The solid rubber bandage, either alone or in connection 
with other remedies, proves of great service here. This method of 
treatment, together with rest, should be persevered in as long as 
any benefit seems to follow its employment. The constitutional 
symptoms accompanying the local disturbance are to be treated as 
the case may seem to require. Quinine is unquestionably of value 
in lessening the severity of the erysipelatous attacks. Iodide of 
potassium is also said to be of benefit in the early stages of the 
disease. The value of change of climate should also be con- 
sidered. In Eastern countries, according to Fayrer, no remedy 
is so potent, and if effected in the earliest stages may completely 
arrest the disease. Ligation of the main artery supplying the limb 
may be practised, but, notwithstanding that some of the results 
have been satisfactory, the operation cannot be recommended. 
Wernherf gives an analysis of the results of treatment by this 
means in thirty-two cases, the femoral being the artery in twenty- 
three cases. In the latter series the size of the leg was imme- 
diately reduced, but the result was permanent in three cases only. 
In four cases in which digital and instrumental compression of 
the femoral was tried, the diminution in size was as rapid and 
the effect as permanent as after ligation of the artery. 

In cases in which the genitalia are involved, the knife offers 



* Endemic and other Diseases of Hot Climates, by Drs. Farquhar and Til- 
bury Fox. London, 1876. 

f Deutsche Zeitschrift fur Chirurgie, 1876. 



420 HYPERTROPHIES. 

the best means of relief. Authors agree that the removal of these 
growths by amputation is comparatively safe and easy. Osgood * 
states that over sixty cases involving the scrotum have been operated 
upon in China within the last fifteen years, and that all, without 
a single exception, have recovered. On the other hand, Fayrerf 
states that out of one hundred and ninety-three cases operated on 
in the Medical College Hospital in Calcutta between 1859 and 
1871, eighteen per cent, proved fatal, some of the deaths, how- 
ever, being due to imperfect sanitary conditions. 

Prognosis. — If the patient be placed under proper treatment 
early in its course, much may be done to arrest the process. When, 
however, the growth has become fully developed, but little per- 
manent relief can be looked for. Striking deformity attends the 
disease, the part involved usually attaining great size and weight, 
while not infrequently, in the course of years, a limb will assume 
huge proportions, resembling in contour as well as in bulk the foot 
of an elephant. The penis, scrotum, and labia likewise enlarge 
at times enormously, forming solid tumors, often weighing many 
pounds, and sometimes as high as a hundred pounds.^ In these 
cases locomotion is interfered with, if not altogether prevented. 
Individuals affected with elephantiasis seldom perish from the 
eifects of the disease, though a fatal result may, in rare cases, 
follow an inflammatory attack. 

DERMATOLYSIS. 

Syn., Cutis Pendula ; Pachydermatocele. 

Dermatolysis consists of a more or less circumscribed 
hypertrophy of the cutaneous and subcutaneous structures, 
characterized by softness and looseness of the skin, and a 
tendency to hang in folds. 

Symptoms. — It may exist as a slight affection, or to such an 
extent as to cause serious inconvenience. The skin and all its 



* On the Treatment of Elephantiasis, with a Tahle of Fifty Cases. New 
York Med. Record, April 8. 1876. 

f Lancet, March 29, 1879. 

X A huge scrotal growth of this character came under ohservation at the 
Hospital of the University of Pennsylvania, and was successfully removed by 
Dr. John Neill. Amer. Jour, of Med. Sci., July and Oct. 1875. 



DERMATOLYSIS. 421 

component parts, including hairs, follicles, glands, and ducts, as 
well as the deeper structures, are hypertrophied. The tissues are 
greatly thickened, bulky, and incline to hang in folds; not uncom- 
monly the layers lap over one another, like the folds of a loose 
garment. To the touch the skin is soft and pliable, and is remark- 
able for its laxity, reminding one of adipose tissue. Its surface is 
rugous, owing to the hypertrophy of the follicles and natural folds 
and lines of the part, and has the appearance of normal skin viewed 
through a magnifying-glass. More or less pigmentation is also 
present, the skin being at times brownish in color. 

The affection may be confined to a certain region, as the back, 
or may show itself in several distinct localities, as upon the face 
and arm. It has been observed to occur about the head, face, 
neck, back, arms, abdomen, genitalia, and thighs. One or a 
number of growths may be present. The course of the disease 
is usually slow. It occasions, as a rule, no annoyance beyond the 
inconvenience of the mass. 

The tissues may develop to an enormous size, as in the case of 
JSTelaton, reported by Keen,* where the disease sprang from the 
neck and shoulders and fell in the form of a huge cloak over 
the whole back, reaching to the buttocks. A somewhat similar 
case presented itself to my notice. The late Valentine Mott was 
the first in this country to call attention to the disease. He reported 
five marked cases, portraits of two of which accompany his commu- 
nication, f A remarkable case, comparing favorably for extensive 
development with the well-known case of Eleanor Fitzgerald 
figured by Bell,! is reported by Fritsche, of Poland. § Stokes, of 
Dublin, also records a case, with a drawing, upon which he per- 
formed a successful operation. || Weeden Cooke's case, which I had 
the fortune to see, may also be referred to. The subject was a girl 
of seventeen, who was affected with an enormous hypertrophy of 
the cutaneous tissues about the left hip and thigh, extending down 
as far as the knee, and there abruptly terminating. The integu- 



* Phot. Kev. of Med. and Surg., vol. ii. p. 45. 
f Med.-Chir. Soc. Trans., vol. zxxvii. p. 155. 
% Principles of Surgery, vol. iii. London, 1808. 

g Trans. Lond. Clin. Soc., 1873. The portrait may be found in Tilbury 
Fox's Atlas of Skin Diseases. 

II Dublin Jour, of Med. Sci., Jan. 1876. 



422 



HYPERTROPHIES. 



ment was greatly hypertrophied, and hung loosely in four or 
five folds, one overlapping the other, which could be lifted up 
separately. It resembled in form the leg of a pair of loose Turk- 
ish trousers. It dated back only three years, and latterly had 
increased with rapidity. 

Pathology.— The growth consists of a simple hypertrophy of 
the integument, including all its parts, and especially of the sub- 
cutaneous connective tissue. Under the microscope it is seen to 
consist largely of soft fibrous or lipomatous tissue, or of both in 
varying proportions. No cause can be assigned for the abnormal 
development; at times it is congenital, in other cases, as in that of 
Mr. Cooke, it does not make its appearance until puberty or later. 
Hebra and Kaposi describe the disease in connection with elephan- 
tiasis, and designate it elephantiasis telangiectodes. They 
state that it is always congenital. Such, however, is not always 
the case with the affection under consideration. It must be re- 
garded as closely allied to molluscum fibrosum, sometimes occur- 
ring with this manifestation. 

Treatment.— The knife offers the only means of removing the 
growth, the advisability of an operation depending upon itsloea- 
tion and extent. 



HYPERTROPHY OF THE HAIR. 

Syn., Hypertrichosis; Hypertrichosis j Trichauxis ; Polytrichia; Hirsuties. 

Symptoms.— Here are included all those cases in which the hairs 
are unusually developed, as regards their size and number, either 
upon regions where the hair is ordinarily found, or in places where 
the growth is abnormal. The hair may be of the average thick- 
ness or finer or coarser than normal. Sometimes a number of hairs 
grow from a single follicle. The hair upon the scalp in both sexes 
not infrequently grows to an unusual length and in great quantity. 
Wilson* mentions several cases in women where it measured six 
feet in length, and I myself have seen a woman in whom it swept 
the ground, the unusual development having begun after a serious 
illness at the age of seventeen. 

The hair in other localities to which it is natural, as the eye- 



* Lectures on Dermatology. London, 1878. 



HYPERTROPHY OP THE HAIR. 423 

brows, axillae, pubes, and beard in men, may also take on aug- 
mented growth and attain uncommon development. Examples 
of long beards reaching to the ground are recorded by Eble,* and 
more recently Leonard f has reported the case of a man, forty-five 
years of age, whose beard measured over seven feet in length, and 
which had been twelve years in attaining this growth. 

Instead of the fine, downy hairs present over the greater por- 
tion of the body, increased activity of hair-growth may mani- 
fest itself, either universally, over the whole surface, or locally, 
in certain parts, as the face, which may continue until the body 
is extensively covered with long, stout hairs. A case where it 
was universal is reported by Wilson,! occurring in an unmarried 
woman, thirty-three years of age, the growth dating from puberty. 
With the exception of the crown of the head, which had only 
lately become bald, the rest of the surface, including the sides of 
the head, the face, neck, trunk, and limbs, was covered with black, 
stiff hair, from half an inch to two inches in length, and thick 
enough to conceal the skin. The woman was robust, but was 
amenorrhoeic and in ill health. The peculiarity of this case is the 
fact that the growth was not congenital. This form of develop- 
ment, whether local or universal, may take place in either sex, and 
at all periods of life. As a local manifestation it sometimes gives 
rise to much disfigurement in women, in the form of a moustache 
or beard, instances of which are not uncommon. Dr. Hardaway § 
and myself || have both reported marked cases. 

Examples of "homines pilosi," or hairy people, the develop- 
ment being, as a rule, both congenital and hereditary, as in the 
case of Shev6maong, the " homo hirsutus" of Burmah, and his 
family, are from time to time met with, extraordinary cases of 
which have now and then been reported.^ Some races, as the 
A'inos, of the island of Yesso, are noted for their excessive hairi- 
ness. 



* Die Lehre von den Haaren. Wien, 1831. 
f The Hair. Detroit, 1880. 
% Lectures on Dermatology. London, 1878. 
§ St. Louis Med. and Surg. Jour., Nov. 1877. 
|| Arch, of Derm., April, 1877. 

^y For an account of such cases, see Wilson, Diseases of the Skin, p. 716, 
London, 1867, and Lectures on Dermatology, London, 1878. 



424 HYPERTROPHIES. 

Stout, stiff, and sometimes long hairs are of common occurrence 
in connection with moles, when the formation is termed 1SMVTJS 
PILOSUS ; while if it possess a rough, uneven, warty surface, it is 
called lOBVUS verrucosus. These growths are encountered upon 
various regions; existing upon the scalp, the hairs are usually 
considerably increased in calibre, so much so at times as to re- 
semble the hair of the lower animals. 

Hairs occasionally show abnormality as regards the direction in 
which they grow, either within or after leaving the follicle, the 
condition being termed trichiasis.. It is met with upon the scalp 
and eyebrows, and upon the eyelashes, where, at times, the hairs 
exhibit a tendency to turn inwards towards the eyeba.ll. 

The condition known as plica or plica polonica (formerly 
common in Poland and observed chiefly among the poorer classes), 
in which the hair, through long-continued neglect, uncleanliness, 
and at times the presence of lice and of eczema, becomes matted 
together in the form of a mop, may be here referred to. It is 
not a disease, as was formerly supposed, but is merely an en- 
tangled, felted state of the hair, brought about by inattention to 
combing and cleansing. It is rarely, if ever, encountered in this 
country. 

Etiology. — Nothing definite can be stated in regard to the causes 
of these abnormal developments. They may be congenital, the 
usual case, or they may be acquired, the disposition to increased 
growth first showing itself later in life. They are more common 
in persons of dark than in those of light complexion. In women, 
when the condition is acquired, as it occurs about the face, marked 
masculine peculiarities are often present. It is prone to manifest 
itself at the climacteric period ; also in connection with uterine or 
ovarian disease, and in sterile women. As illustrative of the 
influence of the uterus over the growth of hair, a case of hirsu- 
ties gestationis, reported by Slocum,* may be quoted. Three 
children were born at full term, and with each gestation a growth 
of hair on the sides of the face and under the chin started at the 
beginning of pregnancy and continued until childbirth, growing 
to the length of one and a half inches. As the catamenial func- 
tion returned, the hair fell out, the face assuming its normal 

* ISTew York Med. Pvecord, 1875, p. 470. 



HYPERTROPHY OF THE HAIR. 425 

smoothness. Hamilton * has called attention to the not infrequent 
occurrence of hairy growths on the faces of insane women ; and 
Fabref has also pointed out striking changes of hair in conse- 
quence of various mental states in women. Hypertrophy of the 
hair is also known to follow nerve injuries, and to manifest itself 
upon paralyzed parts. Local stimulation or irritation may also be 
mentioned as one of the causes. Cases have been recorded, for 
instance, in which lanugo developed into strong, stiff hairs from 
inunctions of oils, and upon the site of a former blister. 

Treatment. — The removal of these augmented growths of hair 
is usually confined to small areas, as, for example, hairy nsevi, the 
upper lip, and the face generally of women. The best method is 
by electrolysis, as recommended by Michel,! Hardaway, § Piffard,|| 
and Fox,1[ to the value of which I can add my own testimony. 
The operation is both simple and safe. It consists in the introduc- 
tion of a fine needle into the hair- follicle and the destruction of 
the hair-papilla by means of the galvanic current. The needle is 
connected with the negative pole ; while the positive pole with 
sponge electrode is held by the patient. I use a No. 12 sewing- 
needle, ground down to the finest calibre (which after many ex- 
periments I have found to be the best), attached to a small holder 
made in the form of a pocket lead-pencil. From six to twelve 
cells of a recently charged galvanic battery are necessary. The 
needle is introduced before extracting the hair, and allowed to re- 
main in contact with the papilla of the hair and follicle until the 
hair is found to be so loose that it may be withdrawn upon the 
least traction. In cases where the base of the follicle has not been 
reached, the needle should be re-introduced. The hair should 
never be extracted until it is detached from the papilla and loose. 

The needle is first introduced, and the circuit then made by the 
patient touching the sponge electrode; to avoid shock, the patient 
should not break the circuit until after the needle has been with- 
drawn. The length of time required for each hair will vary from 

* New York Med. Eecord, 1881, vol. i. p. 281. 

f Les Kelations pathogeniques des Troubles nerveux, p r 513. Paris, 1880. 

% St. Louis Courier of Medicine, Feb. 1879. 

\ Trans. Amer. Derm. Assoc, 1878; also Phila. Med. Times, Feb. 14, 1880. 

|| Diseases of the Skin, p. 807. New York, 1876. 

\ New York Med. Record, March 22, 1879. 



426 HYPERTROPHIES. 

ten to thirty seconds, according to circumstances. Slight frothing, 
more or less congestion, and the formation of a wheal, followed 
sometimes by a small papule, pustule, or reddish spot, occur about 
the opening of the follicle. If the operation be skilfully per- 
formed, no scars, or slight ones only, remain. The amount of 
pain accompanying the procedure, in my experience, varies with 
the individual : it may be slight or decided, but is rarely so 
severe as to be intolerable. In most cases, after a few sittings 
a degree of tolerance is established. It is usually most trying 
about the region of the upper lip, and here and there about the 
neck over the course of certain nerves. A good light is necessary, 
and where the eyesight is at all defective, or where the strain upon 
the eyes is great and often repeated, a lens will prove of assistance. 
The operation should be confined to the removal of the stiffer and 
colored hairs, the lanugo being allowed to remain. The results 
with the latter in my experience have not been satisfactory. In 
the case of hairy nsevi, excision or cauterization of the whole for- 
mation often proves the most effectual and permanent method of 
treatment. 

Depilatories, remedies of a caustic nature which act destruc- 
tively upon the hairs, are sometimes of service in destroying 
patches of hair. They consist usually of several substances 
mixed in varying proportions, the active ingredients being either 
sulphide of arsenic, sulphide of sodium, sulphide of barium, sul- 
phide of calcium, or quick-lime. The sulphide of barium is one 
of the best. I can recommend the following: 

R Barii Sulphidi, sjii ; 

Pulv. Oxidi Zinci, 

Pulv. Amyli, aa sjiii. 
M. 

Another good formula may be given as follows : 

R Sodii Sulphidi, gii ; 

Cretae Praeparatae, ^vi. 
M. 

They are made into a paste, with water, and laid on the hairy 
part to be destroyed, as a thin coating, for ten or fifteen minutes. 
As soon as heat of skin is experienced, the powder should be 



HYPERTROPHY OF THE NAIL. 427 

scraped off and the surface washed and anointed with some bland 
ointment. A starch or magnesia powder may be applied later to 
conceal the signs of irritation upon the skin. 

All such preparations should be employed with caution, and 
only under the direction of a physician : on account of their caus- 
tic properties, they are not infrequently the source of mischief. 
They require to be repeated in their use every few days or as the 
case may demand. 

HYPERTROPHY OF THE NAIL. 

The nail- structure may augment itself in various directions, as 
in length, in width, or in thickness. The term hypertrophy of 
the nail is applied to any increase in size, from whatsoever cause. 
Supernumerary nails are occasionally observed ; so also nails 
upon regions of the body where this structure does not usually 
occur, as upon the extremities of amputated fingers, where no 
rudiment of the matrix can have existed.* 

Hypertrophy may take place as an idiopathic affection, occur- 
ring independently of diseases in other parts of the body ; or it 
may appear in connection with certain general or constitutional 
disorders, as ichthyosis and syphilis. The process may manifest 
itself as a simple increase in the normal growth of the nail, 
termed onychauxis ; or, as is more usually the case, it may be 
attended with changes of color, consistence, and shape. When 
the nail inclines to grow forward and to the side, in a twisted, 
bent, or curved manner, more or less like the horn of a ram, the 
condition is called onychogryphosis. The nails here are usu- 
ally much thickened, hard and horny, yellowish or brownish in 
color, and curved into various shapes. One, several, or all of the 
nails may be so affected. It takes place more frequently upon the 
toes than upon the fingers, and is ordinarily met with in old 
people. The skin immediately around the posterior outer sur- 
face of the nail inclines at times to grow over the back of the 
nail, giving rise to the condition designated pterygium of the 
nail. 

Hypertrophy of the nails is apt to take place as the result of 

* Wilson, loc. cit., p. 709. 



428 HYPEETEOPHIES. 

certain diseases of the skin, as psoriasis, ichthyosis, leprosy, and 
syphilis. The appearances presented in these affections vary, al- 
though usually marked by more or less softening and exfoliation. 
Hypertrophy of the papillae of the matrix occasionally occurs, 
causing the nail to become thickened upon its exposed surface. 
Increase in the coloring matter of the nail, producing yellowish, 
brownish, or blackish discoloration, may also be mentioned as one 
of the abnormal states now and then encountered, existing either 
as an idiopathic affection or in connection with other diseases. 

The nail at times takes on an abnormal direction of growth, 
extending itself laterally into the soft parts. When this occurs, 
inflammation of the skin is apt to be produced, giving rise to 
PAEONYCHIA. The matrix of the nail frequently becomes the 
seat of inflammation and of new formations, followed by changes 
of structure of the nail-substance, the condition being termed 
onychia. It may result from external injuries or from certain 
diseases. Eczema, psoriasis, leprosy, and syphilis are all known 
to attack the matrix. 

Syphilitic onychia is due to the cellular deposit of syphilis 
taking place about the matrix of the nail, which undergoes the 
same pathological changes as this formation is subject to in other 
regions of the body, modified by the peculiar anatomical struc- 
ture of the part. One or more of the nails may be affected. The 
process frequently extends itself to the cutaneous tissues around 
the nail, producing redness, swelling, ulceration, and a copious 
discharge of an offensive, puriform fluid. The nail not infre- 
quently becomes detached from the matrix. 

The vegetable parasites of tinea trichophytina and tinea favosa 
at times make their habitat upon and within the nail, which they 
penetrate in all directions, producing increase in size, and subse- 
quently softening and disintegration of the tissue, the condition 
being termed onychomycosis. Several or all of the nails may 
be attacked. 

Treatment. — This will vary with the cause, which must in each 
case be sought for. Both local and constitutional remedies are 
emploved, either alone or conjointly, according to the nature of 
the affection. Idiopathic hypertrophy of the nail may be re- 
moved by the knife or scissors after the growth has been softened 
by hot-water baths or poultices. It is generally advisable at the 



HYPEKTKOPHY OF THE NAIL. 429 

first operation to remove a portion only of the hypertrophy, on 
account of the liability of the nail to split. 

In-growing nails should receive attention in the avoidance of 
all pressure, frequent cutting, and protection of the soft parts by 
means of lint placed between the nail and the skin-fold. Altera- 
tions in the nail through constitutional diseases, as, for example, 
syphilis, must receive general treatment suitable to the case. Nails 
invaded by fungi are to be treated by parasiticides, together with 
internal remedies, if the latter seem to be indicated. 



CLASS YL 
ATROPHIA— ATROPHIES. 

In this class may be grouped all those affections of the skin and 
its component parts which are characterized by a diminution or 
degeneration of the elements which go to make up the normal 
structure. The changes which take place may be due to simple 
atrophy, as of the pigment in gray hair ; to a combined process, 
including both atrophy and hypertrophy, the atrophy, however, 
predominating, as in vitiligo; or to so-called degenerative atrophy, 
as in morphoea. 

The absence of the proper amount of coloring matter in the 
skin gives rise to more or less disfigurement, varying in degree 
according to the extent to which it is wanting. It may exist either 
as a congenital or as an acquired condition. When congenital, it 
is termed albinism. Acquired absence of pigment in the skin 
may be idiopathic, as in vitiligo; or it may occur in the course of 
other diseases, as, for example, in morphoea. 

The pigment of the hair is frequently absent in part or wholly, 
giving rise to various degrees of canities. The skin itself occa- 
sionally suffers from premature idiopathic atrophy, either in a dif- 
fused or in a circumscribed form, usually the latter, as in the stria? 
et macular atrophica} and in morphoea. The hair of the scalp and 
the scalp itself are frequently the seat of atrophy, as in alopecia 
from various causes and in alopecia areata. Tlie nail is also some- 
times attacked. 

ALBINISM. 

Syn., Albinismus ; Congenital Achroma ; Congenital Leucopathia ; Con- 
genital Leucoderma ; Congenital Leucasmus. 

The condition which has been termed albinism consists in a 
congenital absence of the normal pigment. It may exist uni- 
430 



ALBINISM. 431 

formly over the whole of the surface, in which case it is said to 
be universal; or in the form of circumscribed patches, when it 
is designated partial. As a universal anomaly it is met with in 
people of various races, who have received the name of albinoes. 
These individuals are characterized by the more or less complete 
absence of coloring matter in the skin and hair, and even in the 
iris and choroid coat of the eye. The skin is of a milky-white or 
pinkish color, varying as to shade. The hair of the head, as well 
as of the hairy portions of the body, is also usually white or yel- 
lowish white ; at times it is as white as snow, and has a silvery 
appearance, while in very rare instances it may be red, as in a 
case reported by Folker.* It is, moreover, generally fine, thin, 
soft, and silky. 

The eyes are highly sensitive to light, so much so that they are 
scarcely able to tolerate daylight. The pupils dilate and contract 
constantly, the eyeballs incline to oscillate, and there is almost 
continuous involuntary winking. In color the iris is pale-bluish 
or pinkish, while the pupil presents a pinkish or bright-red appear- 
ance, owing to absence of pigment in the choroid. Albinoes, as a 
rule, are of short stature, and are usually deficient in strength and 
in mental capacity. It is said that they almost always have a 
disposition to diseases of the chest. 

Partial albinism is seen in the negro. It consists of one or more 
variously sized and shaped milky-white or pinkish-white patches, 
which may occur upon any region. The hairs of lanugo which 
may exist upon a patch are b'anched, as in the case of universal 
albinism. The eyes are not deprived of pigment. Negroes thus 
affected are designated "pied" or "piebald," and are not rare in 
our Southern States. Occasionally a re-deposit of pigment takes 
place, the skin which was white becoming again black, as in a case 
reported by Dr. T. F. Wood.f On the other hand, cases are not 
rare where the atrophy of pigment goes on to such an extent that 
large areas of skin become white. MarcyJ gives an interesting 
account of the well-known Cape May albinoes, the mother and 
father being " fair emblems of the African race." In this family 



* Lancet, May 31, 1879. 

f Medical Examiner, July 19, 1877. 

% Amer. Jour, of Med. Sci., 1839. 



432 ATROPHIES. 

there were three negroes and three albinoes. The first two children 
were average male negroes, who were followed by two female 
albinoes. Next came a female black child, and lastly another 
albino, a male. 

Albinism, although of rare occurrence, is met with in all races, 
and among those of cold as well as those of hot climates. It 
occurs in Africa, in the various countries of Europe, and in our 
own country, especially among negroes. The causes are unknown. 
The condition is frequently, although by no means always, in- 
herited. One child only out of a family may be so affected. 

VITILIGO. 

Syn., Acquired Leucoderma ; Acquired Leucopathia ; Acquired Leucas- 
mus ; Acquired Achroma; Acquired Piebald Skin. 

Vitiligo is an acquired disease, consisting of one or more 
usually sharply defined, rounded or irregularly-shaped, va- 
riously sized and distributed, smooth, whitish spots, whose 
borders usually show an increase in the normal amount of 
pigmentation. 

Symptoms. — The disease begins by the appearance of one or 
more variously sized spots, which increase slowly or rapidly in 
size, new ones showing themselves from time to time. The num- 
ber varies from several to a dozen or more; usually, however, they 
are not numerous. Their outlines are well defined and terminate 
abruptly against skin which is generally darker than normal, com- 
monly of a mottled brownish-yellow tint. They have a smooth 
surface, and are on a level with the surrounding skin, being neither 
raised nor depressed. In shape they are for the most part roundish ; 
they are also frequently oval, and at times, especially about the 
face, angular and irregular. In size they vary, according to their 
age and the rapidity with which they enlarge; they are usually of 
all sizes from a small coin to the palm of the hand and larger. 
Ultimately, as they grow towards one another, they coalesce, 
forming larger patches, which may cover the greater part of a 
limb or the trunk. They have a pinkish-white or a milky-white 
color, varying somewhat in shade, which is manifestly due to the 
absence of the normal pigment of the skin. Hairs existing in 
their area may or mav not be whitened. The sebaceous and su- 



VITILIGO. 433 

doriparous secretions remain normal. The skin feels normal to 
the touch. Sensibility likewise is preserved, there being neither 
itching, pain, nor anaesthesia. The increased coloration surround- 
ing the spots is a constant feature ; at times it is present only to a 
slight extent, in other cases it is marked. It is a diffused pigmen- 
tation, becoming more intense as it approaches and touches the 
spot ; beyond, it fades gradually into the healthy skin. 

The disease may appear upon any part of the body, from the 
crown of the head to the feet, upon both hairy and non-hairy 
regions. In the majority of cases it occurs upon the backs of the 
hands, and upon the trunk. The course of the affection is exceed- 
ingly chronic; it usually lasts throughout life, the spots increasing 
slowly in size as well as in numbers, in some cases until the greater 
portion of the skin is involved. The disfigurement is usually 
striking, and proves a constant source of annoyance to the patient, 
especially if the lesions chance to make their appearance on the 
face.* The lesions are usually more pronounced in summer than 
in winter, on account of the surrounding pigmentation being 
darker. 

Etiology. — The affection is rare. It is encountered in both 
sexes, in light-haired and in dark-haired people, more often in the 
latter, and in various races. It usually first shows itself in early 
adult life, although it often makes its appearance in childhood. 
The general health is ordinarily good. It is due to a disturb- 
ance of innervation. It is observed sometimes in connection with 
other diseases of the skin, as alopecia areata, and morphcea. 

Pathology. — The process consists in both an atrophy and a 
hypertrophy of the normal pigment of the skin, which appear to 
take place simultaneously. One part of the skin seems to suffer 
at the expense of the other. Microscopic examination shows a 
total absence of the coloring matter in the whitish spots, while 
the yellowish or brownish discoloration which surrounds each spot 
is found to contain an excess of pigment. 

Diagnosis. — The disease is not to be confounded with chloasma, 
which it resembles. In vitiligo the spots are whitish, clearly 
defined, and surrounded by pigmentation ; in chloasma the spot 
itself is yellowish or brownish, and is unaccompanied by any 



* See Plate M of my Atlas of Skin Diseases. 
28 



434 ATROPHIES. 

whiteness whatsoever. It may also be mistaken for tinea versi- 
color; but here, as in chloasma, the patches themselves are yel- 
lowish, the skin between them being normal in color. The skin, 
moreover, in vitiligo, is perfectly smooth and without desquama- 
tion; in tinea versicolor the surface is always the seat of more or 
less furfuraceous desquamation. The microscope will further aid 
in the diagnosis. It is also to be distinguished from morphcea. 
The affections, however, differ in so many particulars as scarcely 
to permit of confusion in diagnosis; the spots of morphcea may 
always be known by the alteration which takes place in the struc- 
ture of the corium. 

Treatment. — Where the health is impaired, or where there is 
functional derangement, strict attention should be devoted to im- 
proving the general condition. A full tonic treatment, including 
arsenic, which in my opinion is the best remedy, should be per- 
sisted in for some time. In regard t> local treatment, with the 
view of improving the disfigurement, the greatest amount of 
success will attend the removal of the yellowish and brownish 
discolorations immediately around the whitish spots. The hyper- 
trophy of the pigment, rather than the atrophy, is to be treated, 
which is done in the manner described in speaking of the chloas- 
mata. The whitish patches also may be stimulated, as, for ex- 
ample, with acetum cantharidis, pencilled lightly over the surface 
from time to time, with the view of keeping up a congestion of 
the capillaries. The galvanic current may al-o be employed. 
Upon the whole, the treatment of vitiligo is unsatisfactory. 

Prognosis. — It will be found, as a rule, that the spots incline to 
increase in size very slowly, extending over a period of years, until 
a considerable portion of the surface is occupied ; they are seldom 
permanently arrested in their progress. At times, however, they 
cease growing, and remain at a stand-still for the rest of life. In 
rare cases the skin has been known to become normal again. In 
a case under my observation very marked improvement occurred 
spontaneously, in the course of several years. The disease is 
attended by no unpleasant symptoms beyond the disfigurement. 



CANITIES. 435 



CANITIES. 



Syn., Grayness of the Hair; Whiteness of the Hair; Blanching of the 
Hair ; Atrophy of the Hair Pigment ; Trichonosis Cana ; Trichonosis Dis- 
color. 

This may occur either prematurely, early in life, or, as is much 
more commonly the case, later, as the result of old age, when it is 
termed senile canities. Premature grayness of the hair may show 
itself either universally, involving the whole of the hairy system, 
or in places, forming tufts or locks of gray or white hair. The 
color may be of any shade from black or brown to white ; usually 
it is gray. The hairs may be discolored throughout their entire 
length or only at certain points ; the shade may also vary in dif- 
ferent places. Wilson * mentions a case where every hair presented 
a succession of alternate brown and white markings throughout 
its entire extent, the white portion of which he found to be- due to 
the accumulation of minute air-globules in the texture of the hair. 
Canities may occur at any age, but is rarely seen before adult 
life. After the process has taken place, the hairs either remain 
without their normal supply of coloring matter throughout the rest 
of life, or, rarely, after a longer or shorter period, regain it, as in 
the cases cited by Wilson and in others quoted by Leonard.f In 
rare cases several changes of color may occur. Thus, Smythe J re- 
ports the case of a man aged forty-seven, who had up to his thirty- 
fifth year a fair skin with light hair and dark eyes. About this 
time his hair began to turn gray, but the hair which did not turn 
gray turned to nearly jet-black, his skin at the same time assuming 
a dark and bronzed hue. Prentiss § records the case of a young 
lady where the color changed from a yellowish shade to black 
under the hypodermic use of pilocarpi n. The change began after 
two weeks' use of the remedy. The hair may also change its color 
with the seasons, becoming gray in winter and recovering its darker 
color in summer.|| In cases of severe illness the hair may change 



* Lectures on Dermatology. London, 1878. 
( f The Hair, p. 127. Detroit, 1880. 
+ Arch, of Derm., July, 1880. 
\ Phila. Med. Times, July 2, 1881. 
|| Wilson. Lectures on Dermatology, p. 171. London, 1878. 



436 ATROPHIES, 

i 



its color, as from brown to red and from brown to black. Wal- 
lenberg* records a case where after scarlatina, accompanied by 
unusually severe and complete desquamation, the nails and hair 
of the whole surface were shed, and were replaced by a milky- 
white skin and white hair, as in albinoes, the natural complexion 
previously having been dark. Nayler also records an instance of 
white hair following scarlatina, f It may also turn gray from 
nerve injuries, and after ligation of the carotid arterv.+ 

The time which hairs require for complete change of color is 
found to vary exceedingly. The question as to whether they can 
be deprived of their color suddenly— i.e., within twenty-four hours 
—is differently answered by observers, but I think the evidence 
is sufficiently strong for believing that it may so occur. Among 
others, Wilson § and Landois|| may be cited as crediting its occur- 
rence, both observers explaining the phenomenon by the presence 
of a gas- or air-bubble taking possession of the hair. Enough 
cases are on record to prove that such may be the case, reported 
instances of which, historical and of more recent date, may be 
found in the works of Wilson,! Purdon,** Tuke,ff Leonard,+J 
and others. The result usually takes place only under nervous shock 
or strong emotional influence, more particularly fear and grief. 
Hebra and Kaposi,§§ on the other hand, are of the opinion that 
the change can take place only gradually, and consequently that 
the reported cases in which the graying is said to have occurred, 
for example, " in the course of the night" cannot be received as 
absolutely true. Internal remedies do not appear to exert any 
influence in restoring the pigment. Dyeing is the only remedy 
for disguising the condition. 

* London Medical Record, June 15, 1876. 
f Diseases of the Skin, p. 10. London, 1874. 
t Med.-Chir. Trans., 1881, p. 252. 
§ Loc. cit., p. 732. 

|| See an interesting case of " sudden graying of the hair" by this writer in 
Yirchow's Archiv, April, 1866. 
If Loc. cit. 

** Treatise on Cutaneous Medicine. London. 1S7G. 

ft Influence of the Mind upon the Body, Amer. ed., p. 276. Phila., 1873. 
XX Loc. cit. 
\\ Loc. cit., vol. iii. p. 192. 



ATEOPHTA CUTIS. 437 

ATROPHIA CUTIS. 

Syn., Atrophia Cutis Propria ; Atrophy of the Skin. 

Atrophy of the skin is characterized either by a diminution in 
its bulk, or by a degeneration of its elements. Simple atrophy 
is marked by a general decrease in the number of the normal con- 
stituents of the tissue. The skin is thin and more or less wasted, 
and presents a dried, shrivelled appearance. Degenerative atrophy 
exhibits structural alteration, with or without actual loss of sub- 
stance. The tissue so affected is usually somewhat hardened, yel- 
lowish or whitish in color, and has a waxy, fatty, bacony look. 
Atrophy of the skin may be general in character, as in senile 
atrophy, and in certain rare forms of disease ; or it may be partial 
or limited in its invasion, as in atrophic lines and spots. 

It may occur, so far as our knowledge extends, as a substan- 
tive disease (idiopathic atrophy) ; or as a manifest symptom in the 
course of some other disorder, or following injury to one or more 
of the greater nerves (symptomatic atrophy). The former is seen 
in atrophic lines and spots, in morphcea, and in senile atrophy; 
the latter in connection with or following certain constitutional and 
local disorders, as, for example, seborrhoea, lupus, syphilis, and tinea 
favosa. Where the condition is due to a nerve injury, as Mitchell 
has shown,* the tissues often undergo remarkable atrophic changes, 
the muscles wasting, the subcutaneous connective tissue disappear- 
ing, and the skin becoming thin, shrivelled, dry and harsh, and 
yellowish or brownish in color, f The hair and nails may also 
degenerate. 

In this connection, as a result of impaired nutrition, the condi- 
tion known as glossy skin may be referred to, which has been 
described by Paget, % and by Mitchell, Morehouse, and Keen,§ 
and more recently by Mitchell. || The skin (generally of the ex- 



* Injuries of Nerves, and their Consequences. Phila., 1872. 

f The case of neuroma of the skin referred to in this work, where a portion 
of the brachial plexus of nerves was exsected, shows these atrophic changes 
markedly. 

% Med. Times and Gaz., March 24, 1864. 

I Gunshot Wounds and Other Injuries of the Nerves. Phila., 1864. 

|| Loc. cit., p. 155. 



438 



ATROPHIES. 



tremities, especially the fingers) becomes pinkish or reddish, smooth, 
shining and glossy, as though varnished, the lesions resembling 
in appearance chilblains. The parts involved usually become 
devoid of hair, while the skin loses its natural lines, and some- 
times shows excoriations and fissures. It is accompanied with 
burning pain, and follows intractable neuralgia, wounds, and other 
lesions of the nerve trunks. Similar changes sometimes occur in 
progressive muscular atrophy, due to disturbance of nutrition in 
the affected part. Balmer* has collected a series of cases where 
trophic changes, chiefly of the hands, were observed, consisting of 
inflammation of the matrix of the nail, splitting and thickening 
of the nail, excoriations, fissures, ulcerations, (edematous and in- 
flammatory swelling of the skin, hemorrhages, and blebs. 

General idiopathic atrophy of the skin is a very rare condition, 
cases of which have from time to time been reported. Thus, 
with the name "general atrophia cutis," Wilson f describes the 
following case of Mrs. L. The lady, who had previously enjoyed 
good health, became the subject of mental anxiety, was weak and 
poorly, and complained of severe pain in the side, below the heart. 
The skin in a few days became dark, discolored in patches, and 
swollen, especially the hands and feet. After a short time the 
skin about the throat and chest apparently contracted, giving the 
sensation of a person tightly grasping it. * Some months late°r she 
fell into a state of great depression, was sleepless, and refused to 
speak or eat. Both hands were at this time much swollen; later 
they became stiffened. Her hands and feet were always cold, and, 
if she became excited, they, as well as her nose, presented a pur- 
ple tinge. The skin of the arms, face, throat, chest, and neck was 
hard and contracted, and of a dark olive color. Later, she was 
extremely emaciated, and her skin so much contracted as to appear 
too small for her body, and the lower lip fell away from the mouth, 
showing the teeth and gums. Her fingers were bent and contracted, 
and ulcerated. The sensibility of the skin was deadened, and the 
movements of the body were effected with difficulty. The case 
possesses certain features in common with both morphcea and 
scleroderma, and might be regarded as a severe and peculiar form 

• * Archiv der Heilkunde, 1875, p. 327. 
f Loc. cit., pp. 393, 394. 



ATEOPHIA CUTIS. 439 

of either of these diseases. Similar cases are described by Hebra 
and Kaposi* with the name "xeroderma," or "parchment-skin," 
which they regard as a form of diffuse idiopathic atrophy of the 
skin. They describe two cases. The first was that of a girl, aged 
eighteen, who had suffered from the disease from early childhood. 
The skin of the face, ears, throat, neck, shoulders, arms, and breast 
to the level of the third rib was tightly stretched, as if contracted, 
was pinched up into a fold with difficulty, and felt very thin. Its 
surface was smooth in some places, whilst in others fine epidermic 
lamellae peeled off; or there were flat, linear furrows marked out 
on the epidermis, so that the surface appeared as dry as parchment, 
and wrinkled, while the skin itself was highly stretched. In places 
it was of a white color and was without pigment, while elsewhere 
it was abundantly dotted over with disseminated, punctiform or 
lentil-shaped, yellowish or dark-brown, pigmented spots resembling 
those of freckles, giving the skin a remarkable checkered appear- 
ance. Here and there were bright-red pin-head or lentil sized 
telangiectases. The subcutaneous fatty tissue was not markedly 
diminished. Sensibility was not impaired. Beyond a sense of 
tightness, the patient experienced no subjective symptoms. At the 
level of the third rib and at the upper third of the arm the alter- 
ation in the condition .of the skin ceased with an almost abrupt 
line of demarcation. From thence downwards, the skin of the 
mamma?, of the whole trunk, and of the extremities was smooth, 
pliant, fine, and in fact normal. The general state of the health 
was good. Owing to the contraction of the skin, the lower eyelids 
were drawn downwards, and on one side the cornea was ulcerated. 
The nose towards its tip appeared compressed, in consequence of 
the shrinking of the skin. The lips could only be slightly sepa- 
rated from each other. 

The second case was that of a girl, aged ten, who had also suf- 
fered from the disease from earliest childhood. The skin of the 
face, as far as the submaxillary region, and that of the extensor 
surfaces of the arms and hands, showed the checkered pigmenta- 
tion as in the first case. The epidermis, especially on the eyelids 
and on the cheeks, was wrinkled and shrivelled, the lower eyelids 
being drawn down, causing ectropion. In the same way the oral 

* Loc. cit., vol. iii. p. 252. 



440 ATKOPHIES. 



and nasal apertures were diminished. The skin was moderately 
tense, and was with difficulty pinched up into folds. The sub- 
cutaneous tissues were not altered. The nose was the seat of a 
pear-shaped, red, granulating, fissured tumor secreting an offensive 
sanious fluid, which proved to be an epithelioma. Similar cases 
have been reported by Glax* and Geber.f That of Glax bears 
features in common with morphoea, and might be viewed as an 
atrophic form of this disease. 

In this connection the cases described by R. W Taylor t and 
myself,§ under the name of "xeroderma of Hebra/'|| may be re- 
ferred to. Dr. Taylor reports seven cases, three of which* I have 
had the opportunity of examining. Five 'of the cases occurred in 
two families. The disease when fully developed is characterized in 
the first place by the presence of numerous, disseminated, pin-head 
and split-pea sized, yellowish, brownish, or blackish pigmentary 
spots, in no way different in either appearance or nature from leu- 
cines or freckles, occurring chiefly about the face, neck, trunk 
arms, forearms, and hands. Secondly, by the development of pin- 
point, pin-head, and split-pea sized telangiectases, or aggregations 
of more or less circumscribed, dilated capillaries, occurring here 
and there among the freckles, winch, however, are far le>s numer- 
ous than the latter. Thirdly, by variously sized and shaped, mostly 
pin-head to split-pea sized and larger, whitish, smooth, thin glazed 
scar-like, atrophic spots, differing in no essential particulars from 
ordinary atrophic macules. Finally, in the severer forms of the 
disease about the face, there occurred in Dr. Taylor's cases vari- 
ously sized tumors, of the nature of angio-myxoma. 

The course of the disease, according^, Taylor, is as follows 
There occurs first a general hypenemic stage, with dilatation of 
the capillaries, and the subsequent formation of the telangiectases 
After remaining a variable time, these new growths undergo 



* Viertelj. fur Derm. u. Syph, 1874, Heft 1 ; abstract in Arch, of Derm 
vol. l. No. 3. ' 

q t 1 A11 fo- W ^ ner Med - Ztg -' Na 35 ' 1874 ' abstract in Yiert ^J- «* Derm. u. 
Syph., 187?, Heft 1, p. 114. 

% Trans. Amer. Derm. Assoc, 1878. 
I Amer. Jour, of Med. Sci., Oct. 1878. 

|| The name "angioma pigmentosum et atrophicum" has been proposed by 
Dr. Tavlor for the disease. 



ATROPHIA CUTIS. 441 

atrophy, leaving on their site brownish spots, constituting the 
second stage; while the third consists in the continual new growth 
of vessels upon the seat of those already atrophied, and in the 
subsequent atrophy of the skin itself. From a study of the dis- 
ease in my case — a mild one — 'the conclusion reached was that the 
pigmentary lesions occurred first, which were in a variable time 
followed by the development of the telangiectases, which in turn 
contracted, underwent atrophy, disappeared, and were replaced by 
the atrophic macules. It is, however, I think, questionable whether 
the process follows any definite and invariable course. These cases 
constitute an important contribution to the subject, and go to show 
that the disease may be of either a mild or a severe type. All 
the cases, except one, occurred in girls, and in the early months 
or years of life, beginning usually in the first year. The general 
health remained good. 

Hutchinson * reports a case in which great emaciation was at- 
tended by a hide-bound state of the skin. The patient was a young 
Hebrew woman, who became extremely thin, and her face hard, 
stiff, and glazy, so that she could scarcely shut her eyes or her 
mouth. The skin of the trunk and extremities was also in a simi- 
lar condition, though much less marked. An extensive case of 
"unilateral idiopathic cutaneous atrophy" affecting a large por- 
tion of the left abdomen, flank, and leg, with pigmentation and 
hypertrophy of the cutaneous capillaries, is also recorded by 
Atkinson.f 

The cases I have quoted are so rare, and at the same time are so 
peculiar, that their exact place in classification becomes a difficult 
matter, and for the present they may remain where they were 
originally placed, among the atrophies. In my opinion, however, 
some of these cases certainly should be grouped with morphcea, as, 
for example, Atkinson's, or with scleroderma. The group of dis- 
eases of which morphoea and scleroderma may be taken as exam- 
ples, whether they be viewed as hypertrophies or as atrophies, is 
one which must, I think, eventually include certain other forms 
of disease heretofore regarded as different. 



* Loc. cit., p. 344. 

| Kiehmond and Louisville Medical Journal, Dec. 1877. 



442 ATROPHIES. 

STRIJE ET MACULE ATROPHICA. 

Syn., Atrophic Lines and Spots. 

This form of atrophy may be either idiopathic or symptomatic. 

Idiopathic. — The atrophy here occurs without known cause, 
often making its appearance so indolently and gradually that the 
attention of the patient is not directed to the lesion until it has 
existed perhaps for some time. The process may assume the form 
either of lines or streaks (atrophia cutis linearis, stride 

ATROPHICA, LINEAR ATROPHY), 01' of Spots (MACULE ATRO- 
PHIC^) ; the former are much the commoner. The lines are 
usually one or two lines in width, and vary in length from one to 
several inches; the spots are roundish or ovalish,and from a pin- 
head to a pea or a finger-nail in size. When fully developed, both 
forms of lesion possess a smooth, glistening, scar-like appearance; 
are perceptibly thinned to the touch ; are slightly depressed or 
grooved; and have a whitish, or bluish-gray, mother-of-pearl 
color. The lines usually have an irregular, broken, curved or 
undulatory course. A number of them are generally found upon 
the same region, in which case they usually run parallel to one 
another, and almost always in an oblique direction. The spots 
are generally isolated. They may occur upon any part of the 
body, but are most frequently seen about the buttocks, trochanters, 
and pelvis, and on the thighs, upon both extensor and flexor sur- 
faces. They give rise to no inconvenience. They ordinarily run 
a slow course, lasting years. Their cause is obscure. They are 
found in both sexes, and at all periods of life. They are some- 
times met with as one of the symptoms of rnorphoea. 

As stated by Wilson * and Liveing,f and as I myself have 
observed, the lesions (certainly in some cases) first manifest them- 
selves in the form of erythematous spots or lines, of a rose or vio- 
laceous tint, made up of hyperaeniic capillaries (as in the first stage 
of rnorphoea), which sooner or later are succeeded by atrophic 
changes, and eventually by the characteristic lesions which have 
given rise to the name striae et macula? atrophicae. The first stage 
of the process, therefore, is not an atrophy, but rather an hyper- 

* Diseases of the Skin. London, 1867. 
f Brit. Med. Jour., Jan. 19, 1878. 



SENILE ATKOPHY. 443 

trophy. Liveing reports a case which was under observation six 
or seven years, where he was able to note the various stages, in- 
cluding the more or less complete obliteration of the oldest lesions. 
Reference may here be made to cases reported by Wilson* and 
Taylor.f 

The relation of the affection under consideration to morphoea 
suggests itself. They are doubtless due to the same causes. The 
first stage of the lesions, as I have already intimated, is identical 
with that which occurs in the first stage of some cases of morphoea, 
and in several cases I have seen well-marked atrophic lines and 
spots associated with the more characteristic patches of rnorphcea. 
Kaposi J examined an excised atrophic line, and found the epi- 
dermis, especially the mucous layer, much atrophied ; the papilla? 
of the corium almost entirely obliterated ; the connective and 
elastic tissue in very thin bundles ; the bloodvessels few and 
slender ; the fat cells absent ; and the sebaceous glands wasted 
and degenerated. 

Symptomatic. — The atrophy here results from various causes, 
as from extreme distention of the cutaneous tissues in pregnancy, 
in large abdominal and other tumors, and in the mammae during 
lactation. The skin in these conditions becomes enormously 
stretched, and finally forms lines which subsequently atrophy 
(line^e albicantes). According to Langer,§ the lesions are not 
due to rupture but to disarrangement of the connective tissue. 
The connective-tissue bundles of the skin form rhomboid meshes, 
which, when the integument is distended, stretch most readily in 
their long axes. The stria? are the result of violent stretching, 
the bundles in parts becoming parallel and remaining in this 
position. 

SENILE ATROPHY. 

This form of atrophy, as its name implies, takes place as the 
result of old age. The alterations encountered are varied in char- 

* Journal of Cutaneous Medicine, vol. i. No 2, 1867. In this paper will 
be found cases which undoubtedly are examples of morphoea. 

f Arch, of Derm., vol. ii. No. 2, 1876. 

X Loc. cit., vol. iii. p. 262. 

\ Anzeiger der K. K. Gesellschaft der Aerzte in Wien, No. 28, 1879 
Abstract in Lond. Med. Record, April 15, 1880. 



444 



ATROPHIES. 



acter, affecting not only the corium, but also its component parts 
and the subcutaneous tissues. The process may be either simple 
or degenerative; commonly both processes occur together. In 
simple atrophy the integument, especially the corium, is thin; 
the surface, moreover, is dry and wrinkled, more or less discol- 
ored, and shows signs of general emaciation. According to Neu- 
mann,* the epidermis is thinned ; the papilla? of the corium are 
either altogether wanting, or are diminished in size ; the pigment 
changes are irregular, and the hair-follicles either well preserved 
or wasted. The hair is absent, or present only in the form of 
lanugo. The sebaceous glands always exhibit marked changes 
which vary with the region. On the parts supplied with lanugo, 
they are either destroyed or are transformed into cysts (milium); 
where the hairs are large, they are found to be enlarged and dis- 
tended. The sweat glands do not show structural alteration. In 
degenerative atrophy the connective tissue of the corium becomes 
metamorphosed into an infiltration of fine or coarse granular 
matter (granular degeneration), or into a vitreous, homogeneous 
mass (vitreous degeneration). Fatty and pigmentary degenerations 
also occur. 

ALOPECIA. 

Alopecia is a condition of more or less complete baldness, 
resulting from a deficient growth of the hair, irrespective 

OF CAUSE. 

The varieties of alopecia are designated according to the causes 
which have occasioned the disorder, and also with the view of 
expressing their chief characteristic. 

Congenital Alopecia. — Absence of hair, either partial or 
entire, may exist as a congenital condition. Rare cases are re- 
corded in which individuals have been born without hair, as in 
a case reported by Sehede,f where a microscopic examination of 
excised portions of the scalp failed to reveal the presence of hair- 
bulbs. Much more frequently, however, the hairs are scantv, or 
are developed only in certain localities. In these anomalous cases 
an hereditary predisposition to deficiency of hair may usually be 



* Loc. cit., p. 302 ; see also Hebra and Kaposi, vol. iii. p. 258. 
f Arehiv fur Klin. Chir., Bd. xiv. 



ALOPECIA. 445 

noted ; some families are remarkable for the limited supply of 
this structure. 

Senile Alopecia — Senile Calvities — Baldness of Old 
Age. — This manifests itself by permanent loss of hair together 
with general atrophy of the cutaneous tissues. It takes its origin, 
in the majority of cases, about the crown of the head. It is seen 
in elderly and old people, the exact time at which it shows itself 
varying considerably with individuals. Commonly, the hairs 
turn gray, after which, in time, they become thin and dry and 
are cast off, either slowly or rapidly, not to be replaced. As is 
well known, this form of baldness affects men much more fre- 
quently than women ; as yet no satisfactory reason for this has 
been suggested. The hair upon other regions of the body also 
suffers more or less atrophy, but rarely to the same extent, or so 
soon in life, as upon the scalp. The alterations in the cutaneous 
structures found in senile baldness have been studied by Neu- 
mann * and Pincus.f The changes are found to vary somewhat 
according to the chronicity of the case and. other circumstances, 
but usually consist in marked atrophy of the follicles, of the 
sebaceous glands, and of the skin itself. 

Idiopathic Premature Alopecia — Idiopathic Prema- 
ture Baldness — Alopecia Simplex. — The process here may 
take place either rapidly, in the course of weeks or months, or, 
as is generally the case, slowly, through a period of years. The 
hairs may commence to come out at any period after puberty, 
although ordinarily the affection does not begin to manifest itself 
until the age of twenty-five or thirty. ' The scalp throughout the 
process is seen to be apparently healthy, no marked seborrhcea or 
other signs of disease being at any time present. At first only a 
few hairs are from time to time cast off, and these are replaced 
immediately by a shorter and finer growth of hair. Later these 
in turn are shed, and are succeeded by still finer hairs. In the 
course of time even these cease to appear, when complete baldness 
results. On the other hand, the affection at times may be partially 
arrested in its progress, and normal hairs may even be produced 
for a time; but the improvement is not apt to be permanent, and 

.* Lehrbuch der Hautkrankheiten. Wien, 1880. 
f Virchow's Archiv, Bd. xliii. 



446 ATROPHIES. 

sooner or later baldness similar to senile baldness remains. This 
form of alopecia is exceedingly common. It occurs in both sexes, 
though much more frequently in men. As in the case of senile 
alopecia, it ordinarily begins about the region of the vertex, and 
extends itself forward to the forehead, taking in on either side the 
space between the parietal protuberances. Pincus* finds micro- 
scopically an increase of the connective tissue of the corium, and 
a binding down of this tissue to the layers beneath, which, owing 
to the arrangement of the altered mesh-work, exert compression 
destructively on the roots of the hair. The condition, therefore, 
is an induration rather than an atrophy. 

Symptomatic Premature Alopecia. — Here are to be grouped 
a number of forms of baldness, more or less complete, caused by 
various diseases either local or general in their character. The loss 
of hair may be temporary or permanent. Rapid shedding of the 
hair (defluvium capillorum) is apt to follow certain systemic dis- 
eases, as, for example, severe fevers, and is usually a transitory 
affection. Nervous disorders, violent shocks to the nervous sys- 
tem, and mental distress, are also known to occasion either sudden 
or gradual loss of hair. Affections directly involving the seba- 
ceous glands and hair-follicles are to be regarded as the commonest 
causes of permanent baldness. Chronic dry seborrhcea occupies a 
conspicuous position in this connection, and is a fruitful source of 
alopecia, taking place as the result of atrophy of the glandular 
structures. Lupus erythematosus attacking the scalp is also fol- 
lowed by bald patches, which may be permanent. Among the 
local causes, certain inflammatory diseases attacking the scalp, as 
erysipelas, psoriasis, eczema, variola, may be mentioned as giving 
rise to more or less alopecia; in these cases the hair usually returns 
with the general health. Parasitic diseases, as tinea tonsurans 
and tinea favosa, are also common local causes of baldness, the 
condition being usually temporary, the new hairs returning in 
a healthy state unless the follicle has been destroyed. Syphilis, 
leprosy, and other severe constitutional disorders also occasion 
alopecia. 

Syphilitic Alopecia. — Loss of hair may occur at two periods 
during the evolution of syphilis. It is noted as one of the early 

* Berlin Klin. Wochenschr., Nos. 4 and 5, 1875. 



ALOPECIA. 447 

symptoms, and again later, as a result either of circumscribed spe- 
cific infiltration and ulceration upon the scalp, or of the cachectic 
state into which the individual is liable to fall. It may be due 
to a local cause, as a disseminated, erythematous, papular, or pus- 
tular syphiloderm, or to a general cause, unaccompanied by cuta- 
neous lesions. The first variety of alopecia is encountered with 
the early syphilitic manifestations. According to Fournier's ob- 
servations, it generally appears from three to six months after in- 
fection. The hairs become dull, dry, brittle, loose, and are shed 
more or less uniformly from all parts of the head. Sometimes, 
however, the fall occurs in the form of patches. The amount 
shed varies exceedingly; it may be so little as to be scarcely notice- 
able, or in such quantity as to cause partial baldness. Sometimes 
the whole hairy system suffers. The hairs upon other parts of 
the body may be likewise affected. The eyebrows, especially 
in women, are not infrequently affected, the loss being either par- 
tial or complete. The same may be said of the genital region. In 
a short time, however,- especially under treatment, they return, 
permanent alopecia seldom occurring from this form. The dura- 
tion is usually from one to six months. Loss of hair also takes 
place later in the course of the disease, which may or may not be 
reproduced. Permanent localized alopecia is usually the result of 
ulcerative lesions. 

Treatment. — The remedies employed for the relief of the forms 
of alopecia just enumerated vary with the condition of the part 
and the cause of the trouble. Congenital alopecia is rarely so 
marked as to call for treatment. The scalp may be stimulated by 
means of oily preparations and stimulating remedies, such as are 
mentioned in connection with alopecia areata. Senile baldness 
cannot be remedied. Simple premature alopecia requires attention 
to the general health, together with the judicious and prolonged 
use of alkaline or alcoholic lotions, followed by stimulating oils, 
as in the case of alopecia areata. 

Symptomatic alopecia, the result of disease in other parts of the 
body, or of disease complicating the hairs and sebaceous glands, is 
to be treated according to the nature of the primary affection. 
In inflammatory disorders of the scalp, as, for example, psoriasis, 
the inflammatory process is to be arrested by the means, both local 
and constitutional, recommended in speaking of these diseases. 



448 ATROPHIES. 

In parasitic affections the parasite is to be destroyed and the dis- 
eased hairs removed by depilation. The baldness resulting from 
severe constitutional disorders, as syphilis, should receive local 
attention in the form of oily preparations and stimulating lotions 
as well as the proper internal treatment. The management of 
alopecia following chronic seborrhoea of the scalp will be found in 
connection with this disease. The external remedies and prepara- 
tions, more or less modified, referred to in the consideration of the 
treatment of alopecia areata and seborrhoea, may all be employed 
for the various forms of baldness. 



ALOPECIA AREATA. 

Syn., Area Celsi ; Alopecia Circumscripta; Porrigo Deealvans ; Tinea 
Decalvans. 

Alopecia areata is an atrophic disease oe the hairy system, 
characterized by the usually sudden appearance of one or 
more circumscribed, whitish, bald patches, varying in size 
and shape, or of more or less universal baldness. 

Symptoms. — It attacks the scalp, face, axilla', pubes, and other 
hairy parts of the body. Its common seat is the scalp, and next in 
frequency the beard in males. The other regions arc only rarely 
invaded. At times the whole body is affected, when there is more 
or less complete absence of hair. The disease upon the scalp is 
observed to consist of one, two, or more patches of baldness.* 
They are usually roundish, circumscribed, and conspicuous areas 
of disease. Occasionally they are irregular in outline, or assume 
an elongated or ribbon-shaped course. In size they vary from a 
small coin to the palm of the hand. At times they coalesce and 
form patches involving the greater part of one or of both sides 
of the head. Their seat is frequently about the parietal protuber- 
ances and behind the ears, but the occiput as well as other localities 
may also be attacked. The disease is often unilateral. The bald- 
ness is generally complete, the area presenting a whitish, smooth, 
polished surface, often without trace of hair. In other cases 
scanty or straggling hairs are met with here and there. Around 
the border, after the patch has ceased enlarging, the hairs are 

* See mv Atlas of Skin Diseases, Plate N. 



ALOPECIA AREATA. 449 

usually firmly seated in their follicles, and exhibit no sign of dis- 
ease. In other cases, a few small, broken hairs may be detected 
about the margin, resembling the stumpy hairs of tinea tonsurans, 
which have been considered by some as pointing to the parasitic 
nature of the affection. They are in reality atrophied new hairs. 
Not infrequently after the disorder has continued for some time, 
lanugo, or woolly hairs, may be seen upon the surface. These, 
however, unless positive recovery is taking place, are usually shed 
in a variable time. The color of the patch is usually pale or 
whitish, sometimes slightly hypereemic, and altogether different 
from that of the healthy scalp. The follicles are no longer prom- 
inent, but are in great part closed and shrunken, often scarcely 
appreciable, so that the skin becomes thin and smooth, to such an 
extent that it resembles that of an old man. To the feel it is 
soft and pliable. It is dry and free of desquamation and seba- 
ceous matter. The patch in the beginning is either upon a level 
with the surrounding integument or slightly raised or puffed, 
while in its latter stage it is sometimes slightly depressed. Sen- 
sation is generally preserved; at times, however, it is diminished, 
while occasionally, according to Neumann, there is marked "anaes- 
thesia. 

The course of the disease is variable. It generally makes its 
appearance suddenly and without premonition. Often the hair is 
observed to come out during the night, the patient awaking to find 
unexpectedly a handful of loose hair and a more or less bald patch. 
In other cases the fall is more gradual, several days or even weeks 
elapsing before it has all been cast off; in these instances the dis- 
ease is noticed to increase its area day by day until the process is 
arrested. The ultimate size of the area is sooner or later determined, 
after which it rarely increases. It is this characteristic which dis- 
tinguishes the affection from other forms of baldness. Sometimes, 
however, the fall of hair is irregular. Where several patches exist, 
they will usually have been formed one after the other rather than 
at the same time, so that hair may be falling from one region or 
another for weeks or months. The disease may continue months 
or longer, its duration varying exceedingly. In young persons, 
however, it almost always terminates sooner or later in recovery. 
In adults and elderly persons the prognosis is not so favorable. 
Months or years may elapse before complete recovery sets in ; while 



450 ATROPHIES. 

in some cases the hair never returns. When repair sets in, it usually 
progresses rapidly, the hairs appearing first as lanugo and then 
growing as in the case of other new hair. Relapses may occur. 
In other cases, however, the new growth takes place irregularly, 
and is at first weak and pale or mixed as to color, and assumes its 
former character only by degrees. 

The subjective symptoms are usually negative; as a rule, neither 
itching, burning, nor pain is present. The patient is in the 
majority of instances first made aware of the condition by the 
quantity of loose hair and the appearance of the bald patch. In 
some cases, however, the fall of the hair is preceded by itching, 
in other cases by soreness or pain. 

Etiology. — The causes of the disease are not always under- 
stood. It occurs in both sexes, and is encountered among the 
wealthy and the poor. According to the statistics of the Amer- 
ican Dermatological Association, 96 cases were reported out of 
16,863 cases of skin disease. It is non-parasitic in its nature, 
and is not contagious. The origin is beyond doubt to be found 
in a peculiar functional nerve disturbance, causing impaired nu- 
trition. It has been noted to follow injuries, neuralgias, sudden 
nervous shocks, fright, and debility resulting from various causes.* 
The disease is, moreover, known to occur in connection with other 
affections of a markedly neurotic character, as morphcea. It has 
also been noted to follow epilepsy. In many cases, however, no 
appreciable cause for the attack can be assigned. 

Pathology. — The fall of the hair must be viewed as due to 
a state of perverted innervation. The disease may therefore be 
regarded as a trophoneurosis. The suddenness of the attack, an 
important feature in the history of many cases of the disease, can 
be accounted for only by regarding the nervous system as at fault. 
The whole process, indeed, frequently takes place in so short a 
time as to be unexplainable upon any other theory than that of 
want of nerve power. The pale atrophic condition of the patch 
also points strongly to the disease being due to this cause. 

It is from a study of both hair and scalp that a knowledge 



* Numerous instances of the kind are on record. See New York Med. 
Record, 1880, vol. i. p. 694; Lancet, 1881, vol. i. p. 951; Virginia Med 
Monthly, 1881, p. 937. 



ALOPECIA AREATA. 451 

of the nature of the disease is to be gained. For microscopical 
examination of the hairs, either those which have fallen at first, 
or the short, stumpy ones that may at times be found about the 
periphery of the patch, will be found suitable. They terminate at 
the root abruptly in a pear- or club-shaped extremity, instead of 
the long, thick bulb observed in healthy hairs. The bulb is con- 
tracted or atrophied. The root above the bulb retains its normal 
appearance, with the exception of being diminished in size. In 
the shaft, however, may be noticed, as the free end is approached, 
an even and gradual distention, terminating in an oval swelling, 
or bulging, close to the end of the hair, which tapers and finishes 
sometimes in a broken extremity. If the long hairs immediately 
about the border of the patch be examined, the same atrophied, 
shrunken bulb is observed, though in a less marked degree. 
This atrophied condition is also seen in hairs that have lived their 
normal life ; in one case it is disease, and in the other a natural 
process. In alopecia areata, instead of the normal death of the 
hair we have a sudden arrest of nutrition, and a rapid wasting and 
atrophy in consequence. The bulging 'or oval distention of the 
shaft at its end may be explained as follows. The shaft not re- 
ceiving its proper nourishment from the papilla, its extreme end 
Buffers most. The filaments, not being sustained as usual, and 
losing their vitality, tend to separate, thus stretching the epidermic 
membrane and causing the appearance described.* Jamiesonf 
examined a piece of skin removed from a young man, but was not 
able to find any morbid changes in the sebaceous glands or hair- 
follicles, nor in the corium or subcutaneous connective tissue. 

Diagnosis. — Alopecia areata is most frequently confounded with 
tinea tonsurans ; although the suddenness of the attack, the more 
or less complete baldness, the absence of desquamation, the white- 
ness and smoothness of the patch, should enable it to be distin- 
guished from this disease. Difficulty can arise only in old cases of 
tinea tonsurans, where the short, characteristic hairs have disap- 
peared ; but even here more or less desquamation invariably exists. 
Tinea tonsurans begins as a small patch and spreads gradually and 



* See a paper by the author in Amer. Jour, of Med. Sci., July, 1870. Also 
an article by Duckworth, St. Bartholomew's Hospital Keports, vol. viii. 
f Edin. Med. Jour., March, 1879. 



452 ATROPHIES. 

often slowly about its periphery ; the whole process in alopecia 
areata takes place, as a rule, in a short time, after which it usu- 
ally remains at a stand-still. A history of contagion is generally 
found in tinea tonsurans. The microscope should always be em- 
ployed in cases of doubt ; it determines the matter indisputably. 
The appearances found in the two diseases are very different : in 
alopecia areata there are distinct signs of atrophy of the hair, es- 
pecially noticeable about the root, unaccompanied by fungus; in 
tinea tonsurans the trichophyton parasite, consisting of chains of 
spores and threads of mycelium, is present and easy of detection. 
It may be known from tinea favosa by the absence of the charac- 
teristic yellowish crusts, and in the later stage of the disease by 
the absence of cicatricial tissue. Vitiligo is scarcely to be con- 
founded with the disease under consideration, for it is an affection 
of the pigment system only, and is unaccompanied by loss of hair. 
If it occur ujion the hairy parts of the body, the hairs may be 
deprived of their color, but are not cast off. It is commonly a dis- 
ease of the non-hairy parts. Alopecia areata may be diagnosed 
from other forms of alopecia by its peculiar symptoms. 

Treatment. — The results from the remedies which are used in 
the treatment of this affection are exceedingly variable, their 
reputed success in many instances depending more upon the short 
duration of the disease in the case under treatment than upon their 
efficacy. Both internal and external remedies may be used with 
advantage. Internal treatment, however, I consider of the most 
value. It should be persevered with. A general tonic treatment, 
consisting of arsenic, iron, quinine, or cod-liver oil, should be pre- 
scribed. They are our best remedies, and, judiciously employed, 
are in many cases of undoubted value. Arsenic is especially 
serviceable. The general condition in obstinate cases should be 
carefully looked after, and the treatment directed accordingly. 

The various external remedies which have been recommended 
are all more or less stimulating in their action. Alcohol, can- 
tharides, the essential oils, glycerine, castor oil, carbolic acid, tar, 
iodine, turpentine, ammonia, salts of mercury, veratria, acetic acid, 
tannic acid, mix vomica, pepper, and sulphur may be mentioned 
as the most useful remedies. They may be employed in the form 
either of ointments or of lotions, in sufficient strength to produce a 
stimulant or rubefacient effect, once or twice daily, as occasion may 



ALOPECIA AREATA. 453 

require. As a rule, strong preparations are tolerated. Among 
the mercurials the oleate will be found the most valuable, used 
from ten to thirty per cent, strength, and perfumed with one or 
several of the essential oils. Chrysarobin, well spoken of by 
Hutchinson, may also be employed in the form of an ointment, as 
in psoriasis. Before making the application the scalp should be 
washed with water and soft soap, dried with a coarse towel, and 
brushed with a stiff brush until moderately stimulated. No fears 
need be entertained as to the production of increased baldness ; for, 
after the patches have formed, the remaining hairs are generally 
firmly seated. Blistering the patches, by means of a cantharidal 
vesicating fluid, is also serviceable, repeated from time to time, 
according to the sensibility of the scalp. Alcohol constitutes the 
basis of most of the fluid formulae. Carbolic acid with alcohol is 
frequently employed by the writer, as follows : 

R Acidi Carbolici, fgi ; 

Alcoholis, f^i, gvi ; 

01. Ricini, fijii ; 

01. Amygdal. Amar., gtt. x. 
M. 

Cantharides, in the form of an ointment or as tincture, is like- 
wise valuable. As an ointment it may be prepared in the strength 
of from one to three drachms to the ounce. The following for- 
mula contains several desirable ingredients : 

R Tinct. Cantharidis, 

Tinct. Capsici, aa fgiss; 

Olei Ricini, f^ii ; 

Aquae Cologniensis, f^i. 
M. 

Aqua ammoniae has long been esteemed of service. Wilson 
and Duckworth both speak well of it, the former frequently 
employing it- as follows : 

R Olei Amygdalae Dulcis, f^i ; 

■Liquoris Ammoniae Fort., f^i ; 

Spiritus Rosmarini, f^v; 

Olei Limonis, fgi. 
M. Ft. lotio. 

Wilson also recommends frictions with a liniment composed of 



454 ATEOPHIES. 



equal parts of liniment of camphor, ammonia, chloroform, and 
aconite. Erlach and Duckworth have again brought to notice oil 
of turpentine, which they consider valuable. It is to be rubbed 
into the patch with a stiff brush once or twice a day until the 
scalp becomes sensitive. Tilbury Fox recommends vesication of 
the patches, and the following lotic 



tion : 



B Tinct. Nucis Vomicae, f^s 

Tinet. Cantharidis, fgvi; 

Glycerin*, fjii ; 

Aceti Destillati, fjiss ; 

Aquas Eosae, f 3 i i i . 
M. Ft. lotio. 



Hebra and Kaposi make use of the ethereal oils, especially the 
oil of mace, and of the stimulating alkaloids with alcohol. Rind- 
fleisch recommends equal parte of tincture of pepper and glycerine. 
Electricity is also a well-known remedy, and in stubborn cases is 
well worthy of a trial. 

^ Prognosis.— As regards the time which the disease may con- 
tinue, no opinion can be given. Occasionally recovery sets in 
shortly after the fall of hair; at other times months or years will 
elapse before this takes place. The younger the patient, the more 
favorable the prognosis. In rare cases the hair is never com- 
pletely restored. As a rule, in young persons, no apprehension 
as to permanent baldness need be entertained. The individual 
should be encouraged to persevere in the treatment, with a view 
to hasten the cure and at the same time to guard against de- 
spondency, which is apt to occur. 

ATROPHY OF THE HAIR. 

Syn., Atrophia Pilorum Propria. 

Atrophic alterations in the structure of the hair take place as 
the result of various diseases of the scalp, as seborrhea and the 
parasitic diseases; and also as the result of impaired nutrition 
following certain constitutional disorders, as syphilis, fevers, etc. 
In these cases the atrophy is symptomatic. It may attack a part 
or the whole of the hair-substance, and is usually characterized by 
diminution of size, dryness, brittleness, and a tendency to separate 
and split up into its components. Idiopathic atrophy of the hair, 



ATEOPHY OF THE HAIR. 455 

independent of disease in other structures of the skin, also occurs, 
as in the following affections : 

Feagilitas Ceinium. — Fragility of the hair is marked by a 
brittle state of the hair-shaft. The common form is that in which 
the shaft of the hair, either of the head or beard, shows irregu- 
larities and uneven formation in structure, being at one point 
thinner than at another. In addition to this imperfection, the 
free ends manifest a disposition to split into filaments. It may 
occur as a slight abnormality, or, on the other hand, to such an 
extent as to render the crop of hair markedly defective. 

Another form of atrophy of the hair of the beard has been 
described by me,* characterized by marked atrophy of the hair- 
bulb and splitting of the hair-substance, the fission taking place 
within the follicle and producing irritation of the skin. The 
atrophy occurs at the bulbs, and the hairs immediately separate 
into a variable number of stalks, which assume various shapes 
and become often greatly enlarged. The curious feature is the 
atrophy of the bulb and the apparent hypertrophy of the shaft.' 
It is not parasitic. 

Teichoeexis Nodosa. — Another variety of fragility of the 
hair, first described by Beigel,f and designated by him " swelling 
and bursting of the hair," and more recently by Kaposi £ with the 
name trichorexis nodosa, consists in the formation of a series of 
small, spindle-shaped, bulbous swellings, situated at irregular in- 
tervals along the shaft of the hair. They are met with chiefly on 
the beard and moustache, but also upon the scalp, and more rarely 
on other regions. They possess a shining, somewhat transparent 
appearance, and look not unlike the ova of pediculi. The hairs 
readily rupture or break entirely off at the points of distention, 
and leave a bristly, brush-like stump, composed of jagged fila- 
ments. Devergie has also described and reported two cases of the 
same affection under the name of tricoptilosis.§ Cases are also 



* Amer. Jour, of Med. Sci., July, 1878 (with wood-cut). 

f Sitzungsb. der k. Akad. der "Wissenschaft, 1855, Bd. xvii. p. 612. The 
disease was also described by Wilks at about this time in his " Lectures on 
Pathological Anatomy." 

J Hebra and Kaposi, loc. cit., vol. iii. p. 244. 

\ Annales de Derm, et de Syph., No. 1, 1871, 1872. Translated in Amer 
Jour, of Syph. and Derm., vol. iii. p. 254. 



45( > ATROPHIES. 



reported by Billi,* Roeser,f Schwimmer,J Sherwell,§ and S. Kolin || 
The affection may give rise to considerable disfigurement The 
cause is unknown. It is not due to a vegetable parasite. Accord- 
ing to Kohn, the appearances are produced by desiccation of the 
medullary substance of the hair, accumulation of air in the same 
and consequent distention, and, finally, rupture, of the hair-sub- 
stance. Shaving and cutting the hair constitute the best methods 
of treatment, though in the cases reported but little benefit has 
followed either this or any of the other remedies suggested. 

W. G. Smith, of Dublin,! has reported a "rare nodose con- 
dition of the hair," which I think may be viewed as a variety of 
trichorexis nodosa. The case was that of a girl aged nineteen, 
who had partial loss and general thinning of the hair of the scalp 
•The shorter hairs presented a regular succession of numerous dis- 
tinct fusiform, opaque swellings along the shaft, beginning imme- 
diately above the root, like beads on a necklace, one node on an 
average existing on each millimetre of hair. There was no rupture 
of the hair at the nodes, fracture, when it occurred, always taking 
place between the swellings. Brown pigment was found abun- 
dantly in the nude S the internodular portion being devoid of pig- 
ment, and thus the hairs viewed with the naked eve presented the 
appearance of being checkered and were alternately brown and 
white, ^o fungus could be found. The affection differs in several 
particulars from the usual form of trichorexis nodosa. 
. PlED RA.— Under this name another disease bearing resemblance 
in external form to trichorexis nodosa has been described by De- 
senne** and by Moms.ff It is met with in the province of Cauca 
m Colombia, and consists of a variable number of small nodosities 
visible to the naked eye, which are found seated along the shafts' 
of the hair, some surrounding the hair completely, others on one 

* Giornale Ital. delle Mai. ven. e della Pelle. Milano, Agosto, 1872 

t Annales de Derm, et de Syph., Xo. 3, 1878. 

t Viertelj. fur Derm. u. Syph., Heft 4, 1878. 

I Arch, of Derm., July, 1879. 

|| Viertelj. fur Derm. u. Syph., Heft 4, 1881. 

\ Brit. Med. Jour., May 1. 1880. 

7, 187tp P 804) RendUS ' Jl " Ilet ^ 1878 (qU ° ted h} ' T - C ° 1COtt F ° X ' Lancet > Dec - 

8 ISnT^rt 22 ' 'f 9 ' P - 407J alS ° Ch6adle and Morris > L — t, Feb. 

8, 18/9, p. 190 (with wood-cut). 



ATROPHY OF THE NAIL. 457 

side only. They are remarkably hard and gritty. Desenne and 
Morris regard the formation as a fungous growth existing on the 
exterior of the hair. Morris states that under the microscope the 
nodes are seen to consist of a " honeycombed mass of pigmented 
spore-like bodies," the whole mass arising from one cell which buds 
forth in all directions. The affection is not contagious, and is sup- 
posed to be due to the use of a peculiar oil by the natives. It is 
found upon the hair of the head, and chiefly among women. The 
hair is said to have an acid smell. A similar growth is described 
and figured by Beigel, in his work on the hair,* as the " chignon- 
fungus." 

There seems to be still another disease presenting similar fea- 
tures, an instance of which is described by Hoggan,f where the 
nodes upon rupture give out masses of bodies resembling fish-roe 
or the spores of a fungus. The nature of the bodies does not 
seem to be as yet established. The affected hair (of the beard 
and moustache), which had been white, turned brown. 

ATROPHY OF THE NAIL. 

The condition may be congenital ; much more commonly, 
however, it exists as an acquired affection. It is characterized by 
a deficient development or growth of the nail-substance, which is 
either smaller or thinner, than normal ; or brittle and split ; or soft 
and crumbly, according to the cause. The color may be pale, 
whitish and opaque, or dark. The so-called " worm-eaten" con- 
dition of the nail, due to varied causes, is generally of an atrophic 
nature. Atrophy of the nail may occur as a strictly local affec- 
tion, or in consequence of injury or disease of the nerves, or of 
some general disease, as, for example, syphilis. Certain diseases 
of the skin, as eczema and psoriasis, attack also the nails, pro- 
ducing atrophic lesions. The fungi met with upon the skin 
likewise occasionally invade the nail, causing deficient growth or 
partial destruction of the structure. The nails are also subject to 
injurious external influences which may interfere with their proper 
development. 



* The Human Hair. London, 1869. 
f Lancet, Sept. 7, 1878. 



CLASS VII. 
NEOPLASMATA— NEW GROWTHS. 

In this class are grouped a large number of important dis- 
eases, which, although differing in many instances in appearance 
and external characters, consist pathologically of a new growth in 
the skin. The neoplasm may be made up of connective tissue, 
as in the case of keloid, molluscum fibrosum, and xanthoma; 
of a cellular deposit, as in lupus erythematosus, lupus vulgaris, 
syphilis, carcinoma, etc.; of bloodvessels, as in vascular nsevus; 
or of lymphatics or of nerves, as in lymphangioma and neuroma. 

The neoplasmata, clinically, are either benign or malignant in 
their nature. The connective-tissue growths may be said to be 
benign ; while certain of the cellular formations, as, for example, 
leprosy and cancer, are characterized by malignancy, completely 
destroying the tissues which they attack, and at times life. Ac- 
cording to their nature are they unattended by or accompanied 
with pain. The majority are not of a painful nature. They 
pursue a chronic course, ordinarily lasting throughout life; some- 
times, as in syphilis and cancer, they run a comparatively rapid 
course. In many instances they are amenable to operative inter- 
ference. Their general pathology has been already referred to. 

KELOID. 

Syn., Kelis; Kelos ; Fr., Cheloide. 

Keloid is a connective-tissue new growth, characterized 

BY ONE OR MORE IRREGULARLY SHAPED, VARIOUSLY SIZED, ELE- 
VATED, SMOOTH, FIRM, SOMEWHAT ELASTIC, REDDISH CICATRIFORM 

LESIONS. 

Symptoms. — The disease usually commences as a small, pea or 
bean sized, pale tubercle or nodule firmly implanted in the skin. 
It increases in size, as a rule, slowly, years often beino- necessary 

458 J 



KELOID. 459 

for its development as commonly encountered. The form of the 
tumor is generally peculiar. It is made up of a central portion or 
body, together with several or numerous prolongations extending 
into the healthy skin ; at other times it consists of a circumscribed 
growth terminating abruptly against the sound tissues. The shape 
is exceedingly variable ; it may be ovalish, elongated, cylindrical, 
crab-shaped, fungoid, or even in the form of streaks and broken 
lines. It is, indeed, remarkable for the irregularity of its shape. 
In size it likewise varies; it may be pea or bean sized, or as large 
as a hand. Not infrequently it is about the size of a thumb. 
The outline is generally well defined, the disease appearing to 
be half embedded in the tissues. It is more prominent about its 
centre, tapering off towards the periphery. It is elevated, usually 
from one to two or three lines. Its surface is smooth and is gen- 
erally devoid of hair. Taken between the fingers it has a firm, 
dense, slightly elastic feel. Its color is pinkish or reddish, often 
streaked, with usually a shining appearance. 

One, several, or many growths may exist ; commonly, however, 
but one is present. The usual seat is upon the trunk, more par- 
ticularly about the sternal region. Occurring here, the disease is 
apt to extend itself laterally, parallel with the ribs, sending out 
its prolongations in all directions. It is also encountered upon 
the mammae, neck, ears, arms, and other regions. More or less 
pain, and sometimes itching, often accompany the growth; but 
neither of these symptoms is by any means constant. Pain is 
more especially noticeable upon pressure. The course of the dis- 
ease may be either rapid or slow; having attained a certain 
growth, it is apt to remain stationary. It is never attended with 
ulceration. It usually exists throughout life ; occasionally, very 
rarely, it undergoes spontaneous involution. 

Etiology. — Keloid may arise spontaneously, in which case it is 
termed spontaneous keloid. It may also spring up at the site of 
various injuries to the skin, when it is called cicatricial keloid. 
This variety is frequently met with as the result of burns by fire 
or chemicals, cuts, flogging, and wounds of all kinds.* It is some- 
times seen occupying the site of former leech-bites, and also acne 



* A remarkable growth of cicatricial fungoid keloid in a negro is reported 
by Dr. Maury in Phot. Eev. of Med. and Surg., Oct. 1870. 



460 NEW GROWTHS. 



and variola lesions, and not infrequently where the ears have been 
bored about the canal. The difference between the two forms is 
one depending alone upon the cause which has occasioned their 
appearance; microscopically they are identical in structure The 
disease is encountered in both sexes, and usually appears in early 
adult or middle life. It is much commoner in the colored than 
m the white race. According to the statistics of the American 
Dermatological Association, 24 cases were encountered out of 
16,863 cases of skin disease. No cause can be ascribed to the 
spontaneous variety. 

Pathology.— Studies relating to the anatomy of keloid have 
been made by Langhans,* Warren,f Kaposi,* and Schwimmer.§ 
Ihe growth is made up of a dense, fibrous mass of tissue, whitish 
ill color, having its seat in the curium. Microscopic examination 
shows in some cases the horny and mucous layers of the epidermis 
to be normal On the other hand, Sehwimmer in idiopathic keloid 
records atrophy of the epidermis; also the formation of peculiar 
vesicles and nuclei, the disappearance of the papillae, and atrophy 
of the hair-follicles and sebaceous glands. The whole corium is 
occupied by a new formation, consisting of bands of connective 
tissue, arranged generally parallel to the surface of the growth 
The fibres are closely packed together and form a dense mass. 
Cells, as a rule, are rarely encountered, except along the course 
of vessels, especially the arteries, where they are found in layers 
about the walls; they are nucleated and spindle-shaped, and are 
seen to best advantage in the more recent portions of the growth. 
It has been shown by Warren that the disease has its starting 
point in the walls of the vessels. 

Diagnosis.— The symptoms of keloid are so striking in character 
that no difficulty is experienced in the diagnosis. It is most liable 
to be confounded with simple cicatrix, from which, however it 
may be known by its color, outline, elevation, and consistence, and 
frequently by the presence of pain. The disease has nothing in 
common with the so-called Addison's keloid, which is now known 
as morphcea. 



* Virchow's Archiv, Bd. xl. p. 334. 

f Sitzungsb. der k. Akad. der Wissenschaft, 1868. 

t Loc. cit., vol. iii. p. 281. 

I Abstract in Pbila. Med. Times, Sept. 10, 1881. 



MOLLUSCUM FIBKOSUM. 461 

Treatment. — This is usually unsatisfactory, for operative inter- 
ference by means of caustics or the knife is almost invariably fol- 
lowed by return of the disease, and frequently in an exaggerated 
form. Vidal* speaks favorably of multiple scarification in par- 
allel and transverse lines, reporting several cases in which marked 
improvement had taken place, the operation having been origi- 
nally undertaken with the view of relieving the pain. Caustic 
potash offers the most efficient remedy if an operation be 
demanded ; but this should not be entertained if the disease is 
increasing. To allay the pain which is at times present, hypo- 
dermic injections of morphia into the part are particularly useful. 
Chloroform and anodyne ointments may also be prescribed for 
the same purpose. With the view of promoting absorption, 
iodine, and lead and mercurial plasters, are the best remedies. 
Wilson f advises painting the growth with a solution composed 
of one drachm of iodide of potassium, an ounce of soft soap, and 
a like quantity of alcohol, followed by the constant application 
of lead plaster spread on a piece of soft leather. I have derived 
benefit from the use of the plaster alone. 

Internally, iodide of potassium and arsenic have been recom- 
mended ; it is doubtful, however, whether they exercise any influ- 
ence over the growth of the disease. Quinine is said to be of use 
in arresting the paroxysmal pains. 

Prognosis. — Spontaneous involution occasionally occurs ; but 
this event is rare. Not infrequently, having attained a certain size 
the tumor ceases to develop. Its course, as a rule, is that of pro- 
gression, attended at times by temporary arrest of development. 

MOLLUSCUM FIBROSUM. 

Syn., Fibroma Molluscum ; Molluscum Simplex; Molluscum Pendulum. 

MOLLUSCUM FIBROSUM IS A CONNECTIVE-TISSUE NEW GROWTH, 
CHARACTERIZED BY SESSILE OR PEDUNCULATED, SOFT OR FIRM, 
ROUNDED, PAINLESS TUMORS, VARYING IN SIZE FROM A SPLIT PEA 
TO AN EGG OR LARGER, SEATED BENEATH AND IN THE SKIN. 

Symptoms. — These growths occur either singly, or, as is more 
apt to be the case, in large numbers, when they usually occupy 

* Gazette des H6pitaux', Jan. 29, 1881, p. 94. 
f Lectures on Dermatology. London, 1875. 



462 NEW GROWTHS. 

the greater part of the body. They generally assume various 
forms and shapes upon the same individual : at times they are 
semiglobular in shape, and are seated in the skin itself or in the 
subcutaneous tissue; while in other cases they are pedunculated, 
club-shaped, and hang from their pedicles. In consistence they 
are, as a rule, uniformly soft, but when taken between the fingers 
are generally found to have a variable amount of body, the larger 
ones having a somewhat elastic, fibrous feel. They are circum- 
scribed or ill defined according to their form. The skin covering 
them is smooth and normal, pinkish or reddish in color, differing 
somewhat in structure and color according as the tumor is large 
or small, sessile or pedunculated. It may be loose or stretched ; 
hypcrtrophied or atrophied. 

The size of the tumors varies exceedingly. Where multiple, 
they are usually pea or cherry sized, with here and there larger 
ones varying from a walnut to a pear. Various sizes and forms 
are generally present. If single, they are apt to be pedunculated 
and to attain considerable size, sometimes weighing many pounds. 
As to numbers, when multiple, in marked cases, they ordinarily 
exist in hundreds, occupying the greater part of the surface with- 
out regularity of distribution ; they have preference, however, 
for the softer tissues, and consequently develop extensively about 
the trunk. They are never attended with pain, although at times 
their great size and weight render them a source of extreme dis- 
comfort.* They may make their appearance at any time during 
life, often in childhood, and grow more or less rapidly, either 
steadily or interruptedly, throughout life. Having attained a cer- 
tain size, they usually remain stationary ; large, pendulous tumors 
occasionally ulcerate, as in the case of other heavy growths."}" 

Etiology. — The disease is encountered in both sexes and in 
various races. The statistics of the American Dermatological 

* Well-marked examples of the disease, with portraits, reported by Drs. 
Octerlony and Wigglesworth, may be found in the Archives of Dermatology, 
July, 1875, and April, 1876. 

f A benign growth, similar in character to fibrous molluscum, but con- 
taining also adipose tissue, in the form usually of a single, pea-sized, hemi- 
spherical, soft, fleshy tumor, is met with on the face and trunk of middle-aged 
and elderly persons. Its growth is slow, and, having assumed its determinate 
size, it remains without undergoing change. Mr. "Wilson designates it " acro- 
chordon." (See Lectures on Dermatcjogy, London, 1871, p. 98.) 



MOLLUSCUM FIBKOSUM. 463 

Association show 9 cases only out of 16,863 cases of skin disease; 
but the disease is of more frequent occurrence than these figures 
indicate. The cause is unknown. Hebra has made note of the 
fact that all of the patients with this affection who have from time 
to time come under his notice were remarkably stunted in physi- 
cal as well as in mental development. The observation has been 
verified by others, and by myself.* The general health of the 
patient does not suffer. The disease may be inherited, and may, 
moreover, manifest itself in several children of the family.f 

Pathology. — The internal structure of molluscum fibrosum will 
be found to differ somewhat as the tumor is small or large, recent 
or old. A section made through the long axis of one which is 
fully developed shows it to consist of a whitish, fibrous mass, 
from which upon pressure a small quantity of yellowish fluid can 
be made to exude. The growth is dense and compact about its 
base, and is here seen to be made up of coarse, irregular bands of 
fibrous tissue. In the centre it is soft and pulpy, while about the 
periphery the fibres are finer and partake more of the structure 
of the corium. No lines, however, mark these differences. These 
tumors cannot be enucleated, for they are firmly bound down by 
their pedicles to the subcutaneous tissue. Old growths, which 
have assumed a dense fibrous character, are, as a rule, less adhe- 
rent to the corium, and may, therefore, more readily be dissected 
out. The attachments at the base, however, are always secure. 
Under the microscope, small, recent tumors are observed to be 
made up of gelatinous, young connective tissue. The cells are to 
be seen more particularly about the periphery, and are traversed 
by bundles of fine fibrillse. Older tumors consist in great part of 
firm, dense, fibrous tissue, closely packed together. When large, 
the tumors are somewhat vascular about the bases. According 
to Rokitansky and others, molluscum fibrosum starts in the con- 
nective tissue of the deeper layers of the corium. Virchow holds 
that they take their origin in the connective tissue surrounding the 
fat globules, — a view which is likewise entertained by Kaposi,! 
and to which I incline. 

* Phila. Med. Times, March 18, 1876 ; also in other cases. 
. f See a paper, reporting two cases, by Dr. I. E. Atkinson, N. Y. Med. Jour., 
Dec. 1875 ; also a report of three cases by Murray, Lancet, March 22, 1873. 
% Path, und Ther. der Hautkrankheiten. Wien, 1880. 



464 NEW GROWTHS. 

Diagnosis. — Xo difficulty, as a rule, presents itself in arriving 
at a diagnosis. The tumors are to be distinguished from those 
of epithelial molluscum by the fact that they do not possess any 
depression or aperture upon their summits. They are, moreover, 
situated beneath the skin, which structure generally appears 
normal, whereas the epithelial tumors are superficial, and stand 
forth prominently, covered by skin which is usually thin and 
stretched*. They are, moreover, not to be confounded with mul- 
tiple neuromata of the skin, from which they may be known by 
the absence of pain ; nor with lipomatous growths, which are soft 
and lobulated in structure. 

Treatment. — When not too numerous, they may be excised by 
the knife, as in the case of other tumors of a similar nature. If 
large and pedunculated, they may be ligated or removed by the 
galvano-cautery. 

Prognosis. — The affection is one which lasts throughout life. 
Occasionally spontaneous involution takes place on the part of 
some of the lesions. The tumors either continue to increase in 
size and number, or, having attained a certain development, be- 
come arrested in their growth and production. 

XANTHOMA. 

v ., Xanthelasma; Vitiligoidea ; Molluscum Cholesterique (Bazin) ; Fi- 
broma Lipomatodes (Virchow). 

Xanthoma is a connective-tissue new growth, character- 
ized BY THE FORMATION OP YELLOWISH, CIRCUMSCRIBED, IRREGU- 
LARLY SHAPED, VARIOUSLY SIZED, NON-INDURATED, FLAT, OR RAISED 
PATCHES OR TUBERCLES. 

Symptoms. — Two varieties of. the affection are encountered ; the 
macular (xanthoma planum) and the tubercular (xanthoma 
tuberosum i. In the first variety the disease consists of pea-sized 
or larger, usually elongated patches, having their seat in the corium. 
They are on a level with the surrounding skin or are slightly 
raised, and often have the appearance of being inlaid. They are 
usually sharply defined; possess a smooth surface; and to the 
touch are soft and apparently normal in texture. In shape they 
are either roundish or elongated; occurring upon the eve! ids, they 
commonly assume the form of narrow semicircular patches, two or 



XANTHOMA. ' 465 

three lines in width, often extending from one can thus to the other. 
In color they are yellowish, the shade varying from buff to orange. 
Sometimes they have a pale, whitish-yellow, or creamy color. 
They are opaque, and resemble patches of chamois-skin. One, 
two, or more may exist, situated either closely together, as about 
the eyelids, or in different regions. They may coalesce. They 
begin as small pin-head or pea sized formations, and increase in 
size, as a rule, slowly, in the course of years. The common seat 
of this variety is about the eyelids, especially the upper ; but it is 
also seen occasionally upon other portions of the face, as well as 
upon the body. The patches seldom give rise to any inconvenience. 

The tubercular form shows itself as pin-heacl, pea, or larger 
sized, roundish, raised patches or tubercles. In general charac- 
ters the lesions do not differ materially from those of the flat 
variety. They are, however, seldom encountered upon the eyelids, 
but usually develop upon the neck, body, and extremities. They 
are sometimes slightly painful. Both forms may occur together. 

The disease is encountered usually in middle or advanced life. 
Sometimes, however, it is met with in the young, as in a case of 
the multiple form of the disease reported by T. Colcott Fox,* 
where it began in the second year. The lesions may be single or 
few or, on the other hand, numerous. The multiple form (xan- 
thoma multiplex) is rare. In the majority of cases the disease 
manifests itself on the eyelids in the macular form, beginning at 
the inner can thus. Next it invades the palms and soles, face, ears, 
flexures of the joints, extremities, and lastly the trunk. It may 
also affect the mucous membrane, the macular form occasionally in- 
vading the lips, gums, tongue, palate, and trachea. Similar opaque 
patches have been found in the spleen and lining membrane of the 
bile ducts. The disease in almost all cases develops gradually; 
runs a slow course ; and usually continues throughout life. Rarely, 
it develops rapidly, as in Korach'sf case of universal xanthoma 
planum et tuberosum, which manifested itself with icterus and 
pruritus in the course of a few weeks. After a year the icterus 
disappeared and the xanthoma faded considerably. It may disap- 



* Lancet, Nov. 8, 1879. 

f Deutsche Med. Wochenschr. , No. 23, 1881. Abstract in Phila. Med. 
Times, Aug. 27, 1881. 

SO 



466 



NEW GROWTHS. 



pear spontaneously, as in the instances reported by Fagge,* W. F. 
Smith,t and Legg.J It is more common in women than in men. 

Etiology.— The causes are obscure. In a number of the re- 
ported cases jaundice had occurred previously or was present. In 
many cases, however, no history of jaundice or of liver disease 
can be found. In the multiple form of the disease, according to 
Pye-Smith, there is usually a history of jaundice, often due to an 
organic cause, although Fox§ and Carry || have recently recorded 
instances in which there was neither antecedent disease of the 
liver nor jaundice. Pye-Smith! and Tilbury Fox ** both express 
the opinion that the disease is probably due to the circulation of 
bile-pigment in the blood. This statement, however, cannot be 
accepted for all cases. White ff refers to ten cases, observed by 
himself, in which no such cause could be assigned; and my own 
experience has been the same. Xanthoma palpebrarum, the mac- 
ular form, is seldom associated with jaundice. 

Pathology.— The disease is a connective-tissue new growth with 
fatty, degeneration, a view entertained by the majority of those 
who have investigated the subject, among whom Pavy,||Smith,§§ 
Fagge, \Valdeyer,|||| Virchow,!!and Kaposi*** maybe mentioned. 
Pye-Smith,tft who also has carefully studied the disease, concludes 
that it "consists anatomically in a chronic hyperplasia of the 
deeper layer of the cutis, in which the papilla and epidermis on 
the one hand and the subcutaneous connective tissue on the other 
are only secondarily involved. The process may run in two direc- 
tions. When it follows what may be called the inflammatory 
type, the minute, round, inflammation-cells or young leucocytes 
never form true tissue elements, molecular fatty degeneration 
rapidly overtaking them, and leading to their ultimate disappear- 



* Trans. Lond. Path. Soc, vol. xix. f Ibid., vol. xxviii. 

X Lancet, Oct. 25, 1879. g Lancet, Nov. 8 1879. 

|| Annales de Derm, et de Syph., 1880, tome i. No. 1. 

f Trans. Lond. Path. Soc, vol. xxviii. 

** Epitome of Skin Diseases. Phila., 1879. 

ff Bost. Med. and Surg. Jour., Oct. 23, 1879. 

Xt Guy's Hospital Exports, 1866. 

\\ Journal of Cutaneous Medicine, Oct. 1869. 

Illf Yirchow's Archiv, 1873. flfl Ibid., 1871. 

*** Path, und Ther. der Hautkrankheiten. Wien, 1880. 

ttt Guy's Hospital Pveports, 1877. 



XANTHOMA. 467 

ance in a detritus of oil-drops, calcareous masses, and cholesterine 
crystals." The other course the disease may take approaches the 
process of formation of a true new growth; the new cells, instead 
of quickly dying by fatty degeneration, grow to a considerable 
size and develop processes, so as to form the fusiform and stellate 
corpuscles of connective tissue. These cells are also liable to fatty 
degeneration, but the process is slower and less destructive, and re- 
sembles the normal transformation of ordinary connective into 
adipose tissue. 

Treatment. — When interference is called for, the only plan of 
treatment is that of excision, which may be, as a rule, satisfactorily 
accomplished. In order to avoid ectropion, when the affection is 
upon the eyelids, care should be taken not to carry the incision 
around the patch too deeply into the tissues. After removal the 
edges are to be brought together by stitches, and the case treated 
as an ordinary wound. 

Mention may here be made of colloid degeneration of the 
skin, cases of which have been reported by Wagner,* and more 
recently by Besnier.f It is characterized by numerous, dissem- 
inated, small, pin-head sized, discrete, rounded, flat or slightly 
raised lesions, of a pale or bright lemon color. They are shining 
and translucent, and have the appearance of being yellowish 
vesicles. Their appearance, however, is deceptive, for they are of 
firm or solid consistence. When pricked with a needle or opened 
sufficiently deep to cause bleeding, a whitish or yellowish, trans- 
parent, gelatinous substance may be expressed. The disease occurs 
chiefly upon the face, especially the upper half, about the bridge 
of the nose, the orbital and temporal regions, and the forehead. 
It is met with in middle-aged or elderly persons. It may resemble 
xanthoma, but the lesions differ in being bright and translucent. 
Wagner regarded the disease as a form of milium which had 
undergone colloid degeneration, but Besnier has shown that the 
process is a colloid degeneration of the connective tissue of the 
corium, having its seat in the upper strata, beneath the papillary 



* Das Colloid-Milium der Haut. Archiv der Heilk., 1866, Bd. vii. p. 463. 
f Sur un cas de degenerescence colloide du derme. Gaz. Hebdom., No. 41, 
Oct. 10, 1879. Also Annales de Derm, et de Syph., 1879, tome x. Nos. 5-6. 



468 NEW GKOWTHS. 

layer, the epidermis, glands, and hair-follicles being involved only 
secondarily through pressure. The process is purely degenerative. 

RHINOSCLEROMA. 

Rhinoscleroma consists of a circumscribed, irregularly 
shaped, flattened, tubercular, remarkably hard and dense 
cellular new growth, having its seat about the region of 

THE NOSE. 

Symptoms. — The disease was first described by Hebra and 
Kaposi.* The growth, which may be either roundish or angular 
in outline, is well defined by an abrupt ridge or line of demar- 
cation, beyond which the tissues are normal. It is more or less 
elevated above the surrounding skin, and possesses a flattened, 
plate-like, but uneven surface, caused by the presence of variously 
sized, isolated, aggregated or confluent tubercles of which the mass 
is composed. These are either of the color of the normal skin, or 
are reddish or brownish. The tissues are firmly bound down, as 
in the case of scleroderma, and cannot be taken up between the 
fingers; the epidermis is dry, with here and there fissures which 
secrete a viscid fluid which forms into yellowish, adherent crusts. 
The growth is exceedingly dense, and may be compared to the 
hardness of wood or stone. Upon pressure it is slightly elastic, 
and at the same time painful ; at no stage does it appear either 
inflammatory, swollen, or cedematous. The disease is confined to 
the nose and contiguous parts. It attacks especially the aire, the 
septum, encroaching on the mucous membrane, and the upper lip. 
Its course is remarkably slow, lasting over a period of years. As 
it progresses, the induration usually becomes very marked, the 
alee narrowing in calibre, so that occlusion may take place. The 
nodules or tubercles rarely change in their structure, even though 
they exist for years. Zeissl,f however, reports a case that broke 
down and ulcerated with suppuration. 

Etiology. — Its cause is unknown. It is not due to syphilis. It 
is encountered in both men and women, usually at middle age. 
It is a rare disease. Kaposi | reports having seen twenty-five 

* Wien. Med. "Wochenschr., No. 1, 1870. 

f Ibid., No. 22. 1880, p. 621. 

J Path, und Ther. der Hautkrankheiten. "Wien, 1880. 



RHINOSCLEROMA. 469 

cases. It is certainly very rare in this country. I am not aware 
of any cases having been observed here. 

Pathology. — Kaposi* remarks that, on cutting into one of the 
tubercles of rhinoscleroma, one is surprised at the ease with which 
the knife makes its way in comparison with the hardness which 
is apparent to the touch. The cut surface is of a pale-red color, 
uniformly and finely granular, and bleeds freely. The micro- 
scopic anatomy has been carefully studied by this observer, also 
by Geber,f and more recently by Mikulicz.! Kaposi gives the 
following result of his examinations. The epidermis and rete are 
normal. The papilke are filled with small cells closely packed 
together, the cellular infiltration, here and there, extending deeply 
into the corium, which is uniformly dense throughout, the vascular 
stratum and the papillae being especially crammed full of cells. 
The cells are smaller, especially in the protoplasm, than the so- 
called granulation cells usually are, as met with in acute or chronic 
inflammation of the skin, and also in places where a new growth 
of connective tissue is taking place. The nuclei of the cells are 
small and refract light feebly, and are finely granular. The cells 
appear to be simply lodged in the delicate connective-tissue stroma 
of the papillae and the upper layers of the corium, and can easily 
be removed by manipulation. They are, moreover, well pre- 
served, and have a sharp outline and distinct nuclei, differing in 
this respect from the degenerative cells of lupus and syphilis. 
The deeper layers of the corium show a dense connective-tissue 
felt. The growth, according to Kaposi, must be viewed as allied 
to the small-celled or granulation sarcoma. The same anatomy 
is described by Geber and Mikulicz, who, however, interpret the 
disease as a chronic inflammatory process. 

Diagnosis. — The location of the disease, the extreme hardness 
of the path, the sharp line of demarcation, the alteration in the 
shape of the nostrils, and its slow course, will usually serve to 
distinguish it from other affections. It may be confounded with 
syphilis, keloid, and epithelioma, but upon investigation will be 
found to differ from these diseases in many particulars. 



* Loc. cit., vol. iv. p. 7. 

f Archiv fur Derm, und Syph., 1872, Heft 4. 

X Archiv fur Klin. Chir., Bd. xx. 



470 NEW GROWTHS. 

Treatment. — The disease calls for interference, for, if permitted 
to increase, occlusion of the nostrils may occur. It is to be de- 
stroyed by means of caustics, the nitrate of silver, potash stick, or 
pyrogallic acid, being the best remedies. No inflammatory action 
is set up, nor does the part ever assume a malignant character in 
consequence of the operation. The disease tends to recur. 

Prognosis. — This is unfavorable. It is extremely obstinate, 
and, "without treatment, usually continues a lifetime. 

LUPUS ERYTHEMATOSUS. 

Syn., Lupus Erythematodes ; Seborrhcea Congestiva; Lupus Superficialis ; 
Lupus Sebaceus; Germ., Lupus Erythematosus ; Fr., Scrofulide Erythema- 
teuse ; Erythema Centrifuge. 

Lupus erythematosus is a cellular new growth, character- 
ized BY ONE OR MORE, CIRCCMSCRIBKD, ROUNDED, OVOID, OR IRREG- 
ULARLY SHAPED, VARIOUSLY SIZED, REDDISH PATCHES, COVERED WITH 
GRAYISH OR YELLOWISH, ADHERENT SCALES. 

Symptoms. — The disease begins either in the form of a single, 
usually roundish, circumscribed patch, which, enlarging upon its 
periphery, increases indefinitely in size; or, in the form of two or 
three or a number of isolated patches, which gradually approach 
one another, and coalesce t<> make one or more larger patches. 
The lesions, at first, are small, pin-head or pea sized, erythema- 
tous spots, which ordinarily make their appearance slowly. Tinw- 
are usually circumscribed from the beginning, and generally ex- 
hibit a margin or bonier covered with grayish or yellowish Bcales. 
As a rule, they extend gradually; at times, however, they a— nine 
considerable size in the course of a month or two. 

When fully developed, the disease con-ists of one, two, or a num- 
ber of patches, varying in size from a split pea to a silver quarter 
dollar or the palm of the hand, having generally a distinctly 
denned, marginate outline. In shape they are usually roundish 
or ovalish, but they are often irregular. In color they are reddish 
or violaceous, the shade varying. The surface is covered with fine 
or coarse, grayish or yellowish adherent scales. These are usually 
scanty; at times, however, they are so abundant as to form 
ceous-looking crusts, similar to those met with in seborrhrea of the 
face. They are firmly attached to the openings of the sebaceous 



LUPUS ERYTHEMATOSUS. 471 

glands, which are often distended and patulous. The patch 
spreads upon its margin, the border being well defined, while the 
central portion usually shows a paler color, slight depression, and 
a tendency to atrophic change. After a variable time the patch 
attains a certain size, and may remain stationary. There is never 
any moisture or discharge in connection with the disease. 

The usual seat of the affection is upon the face. The cheeks, 
especially below the eyes, and the bridge of the nose are most 
frequently attacked. When these regions are at the same time 
invaded, the symmetry is ordinarily so marked that the eruption 
presents an appearance not unlike the form of a bat or butterfly 
with outspread wings.* The red of the lips, ears, scalp, back, and 
other parts of the body may likewise be involved. The disease is 
notable for its chronicity, and may persist through life. It tends 
to increase from time to time by repeated attacks, at short or long 
intervals. Ultimately the process generally ends in the formation 
of a whitish or yellowish, punctate, soft or firm, cicatricial tissue, 
which may be either superficial or deep-seated. 

The subjective symptoms are variable, and depend upon the 
activity of the disease ; as a rule, there is burning or itching, con- 
stant or intermittent; while in other cases but slight discomfort is 
experienced. The general health is usually good, and ordinarily 
remains so. According to Kaposi, erysipelas, adenitis, and sub- 
cutaneous swellings of a peculiar character may complicate the 
disease. I have never encountered such symptoms. 

Etiology. — The causes are obscure. It is one of the rarer dis- 
eases of the skin. According to the statistics of the American 
Dermatological Association, 43 cases were encountered among 
16,863 cases of skin disease. Females are more liable to it than 
males. It seldom occurs before puberty, differing in this respect 
from lupus vulgaris. It attacks persons of all temperaments, but 
is most commonly met with in those with light skin and hair, and 
notably upon those who are subject to disorders of the sebaceous 
glands. Not infrequently it originates in causes similar to those 
which produce seborrhoea; it is well known that lupus erythema- 
tosus may begin as a localized seborrhoea. 

Pathology. — The disease possesses the nature both of an inflam- 

* See Plate C in my Atlas of Skin Diseases. 



472 KETT GROWTHS. 



mation and of a new growth. It occupies a position possibly 
between the two pathological classes of disease. In the li^ht of 
recent observation it is regarded by some as a chronic inflamma- 
tion of the cutis, leading to degeneration and atrophy. As a 
ru e, it has its seat primarily about the sebaceous glands and fol- 
icles. Hebra first pointed out that the disease had its chief seat 
here, and gave it the name "seborrheal congestiva/' which, however 
is now known to be the case only in certain instances. Kaposi * 
and rhmt have shown that the sweat glands as well as the seba- 
ceous glands may be the seat of the disease, while, according to 
Gebert and Stroganow,§ all the structures and every layer of the 
skin, even to the subcutaneous connective tissue, may be at one 
time or another, the seat of origin and the chief centre of the 
morbid process. 

In recent foci of disease are found not only collections of cells 
about the follicles and glands, together with the usual histological 
signs of inflammation, but also, according to Kaposi, dilatation of 
the vessels, oedema, cell-infiltration of the connective tissue, and 
proliferation of connective-tissue corpuscles. They may occur in 
Hie lower portion of the corium or in the most superficial parts. 
The effect of these histological changes is seen in the proliferation 
of the gland cells, giving rise to seborrhea, the infiltration and 
swelling of the skin and the desquamation of the epidermis form- 
ing clinical features of the disease. If retrograde metamorphosis 
take place in the earlier stages of the pathological process, the 
cell-infiltration is absorbed and the patches disappear without 
leaving any trace behind. Usually, however, the inflammatory 
changes lead to degenerative metamorphosis in the affected tissues, 
resulting in absorption and atrophy. When the glands and hair- 
toJJicles are involved, cicatricial atrophy results 

Diagnosis—When fully developed, the patch offers such a 
striking picture that there is little danger of confounding it with 
any other disease. The region attacked, generally the flee, and 
usually the cheeks and nose; the circumscribed, roundish, reddish 



* Path, und Ther. der Hautkrankheiten. "Wien, 1880 
t Med.-Chir. Trans., vol. lviii., 1875. 
X Viertelj. fur Derm. u. Syph., III. Jahrg., 1876, Heft 1 
§ Centralbl. fur Med., 1877, No. 48. 



LUPUS ERYTHEMATOSUS. 473 

patch with a border ; the adherent, grayish or yellowish scales ; 
and the slow course, all point directly to the disease. 

It is to be distinguished from lupus vulgaris by the absence 
of papules, tubercles, and ulceration. In lupus erythematosus the 
openings of the sebaceous glands are generally enlarged ; they are 
not affected in lupus vulgaris. Lupus erythematosus rarely shows 
itself before puberty; lupus vulgaris usually appears in child- 
hood. Lupus erythematosus is a comparatively superficial dis- 
ease ; lupus vulgaris is deep-seated, and attended sooner or later 
with ulceration and disfiguring cicatrices. Psoriasis may at times 
bear some resemblance to lupus erythematosus, but may be dis- 
tinguished by its course, as well as by symptoms peculiar to it. 
The disease cannot well be mistaken for syphilis; its character- 
istic features, history, and course will prevent such an error. 

Treatment. — The disease is, as a rule, remarkably rebellious to 
the influence of therapeutics. Internal remedies are to be selected 
to meet the needs of the case. At times patients are otherwise 
in perfect health, in which case external treatment alone is to be 
relied upon. In some cases iodine and arsenic may be used with 
advantage. Iodized starch is recommended by McCall Anderson. 
It is made in the proportion of twenty-four grains of iodine to 
one ounce of starch, the iodine being triturated with water and 
the starch gradually added. The dose is a teaspoonful or more. 
Iodide of potassium may also sometimes be prescribed with benefit. 
Cod-liver oil, in some instances, will be found to exert a marked 
influence upon the disease, especially in those cases where there is 
a tendency to impaired general nutrition. 

The external treatment will, however, as a rule, be found to be 
of the greatest value. In the milder forms of the disease it must 
be remembered that the patches sometimes disappear spontane- 
ously, leaving little or no scar, and that therefore no local meas- 
ures should be employed likely to lead to more disfigurement than 
would be caused by the disease itself. Stimulating and caustic ap- 
plications are followed, as a rule, by the best results. Among 
the remedies employed, sapo viridis occupies a prominent position. 
In mild cases the disease may occasionally be relieved by this 
means alone. It may be applied spread upon a cloth, in the form 
of a plaster. It may also be used with water. In combination 
with alcohol, two parts to one of alcohol, it is even of greater 



474 NEW GROWTHS. 

value. The patch is to be well rubbed and washed with it until 
the scales have been completely removed, when a weak glycerine 
lotion or simple ointment may be applied; in some cases it is 
expedient to make no after-application. Apart from the remedial 
effect, the soap serves as an admirable means of cleansing the 
patch for further treatment. 

Oleate of mercury, five or ten per cent, strength, I have found 
valuable. Mercurial ointment is of service in some cases, pre- 
pared as a plaster and applied continuously. Sulphur at times 
proves very serviceable, in the form of an ointment, a drachm or 
more to the ounce, especially when used in conjunction with soft 
soap. It is of more value than is generally supposed. In acute 
superficial cases, attended with heat, the alcoholic sulphur lotions 
referred to in acne are useful. Chrysarobin and pyrogallic acid 
may also be referred to, and have been used with success in the 
form of ointments, from a scruple to a drachm to the ounce. 
Carbolic acid is in some cases followed by satisfactory results; 
likewise tar in the form of a mixture or as an ointment. A mix- 
ture containing equal parts of oil of cade, alcohol, and sapo viridis, 
to be rubbed into the patch morning and evening, often proves a 
valuable stimulating remedy. Tincture of iodine, alone or with 
glycerine, as recommended by Hebra, at times acts favorably. 
Anderson also speaks well of this treatment, and gives the follow- 
ing formula: Iodine and iodide of potassium, of each half an 
ounce; glycerine, one drachm. The part is to be painted until a 
coating forms. 

Stronger applications, caustics, are often demanded in obstinate 
cases, but they should never be used until milder remedies have 
been tried. A solution of caustic potash, one part to six or twelve 
of water, may sometimes be used when other remedies have failed. 
It should be applied by means of a charpie brush, eare being taken 
not to permit its action to extend too deep into the tissues; dilute 
acetic acid should be used immediately afterwards. The after- 
dressing should consist of water, glycerine, or a simple ointment. 
Anderson reports favorable results in certain cases from the re- 
peated use of cautharidal blistering fluid. The acid nitrate of 
mercury, corrosive sublimate, chromic acid, nitric acid, chloride 
of zinc, nitrate of silver, arsenic, red iodide of mercurv, in various 
strengths, have all been used, but without notable success. They 



LUPUS VULGARIS. 475 

should always be employed cautiously, on account of their destruc- 
tive properties, as well as on account of the pain they cause. 

The treatment by means of erasion with the " curette," or 
scraping spoon, as described under lupus vulgaris, has proved 
successful in many cases. Hebra, Kaposi, Auspitz, Neumann, 
and Wigglesworth * all speak well of it. Multiple scarification or 
puncturing, as originally recommended by "Volkmann for lupus 
vulgaris, is said by Veiel and Kaposi to have a corresponding 
effect in lupus erythematosus. The galvano-cautery has also been 
successfully employed in some cases. 

Prognosis. — This should be guardedly expressed. When fully 
developed, it almost always proves stubborn. Occasionally it yields 
more kindly to treatment. The result will depend upon the ex- 
tent of the disease, its distribution, the number of patches, the 
activity of the process, and its duration. Eelapses are liable to 
occur. 

LUPUS VULGARIS. 

Syn., Lupus Exedens ; Lupus Yorax ; Noli Me Tangere ; Germ., Fres- 
sende Flechte ; Fr., Herpes Esthiomenos ; Dartre Eongeante; Scrofulide 
Tubereuleuse ; Esthiomene. 

Lupus vulgaris is a cellular new growth, characterized 
by variously sized and shaped, reddish or brownish patches, 
consisting op papules, tubercles, or flat infiltrations, usu- 
ally terminating in ulceration and cicatrices. 

Symptoms. — The disease presents a number of appearances as it 
assumes one form or another, and as it is seen in the various stages 
of its development. It commonly begins in the form of numer- 
ous, small, grouped or disseminated points, situated beneath the 
epidermis. These are reddish, brownish, or yellowish in color, 
and have their seat within the structure of the corium, often giv- 
ing the skin a punctate appearance. They ultimately constitute 
irregularly shaped, roundish or serpiginous, ill-defined patches, 
varying in size, which not infrequently coalesce. The puncta, or 
subcutaneous points, referred to, increase in size and become more 
prominent, resulting in the formation of papules and ultimately 
tubercles (lupus tuberculosus). It is at this stage that the 

* See a paper by Dr. Wigglesworth, describing the curette and the manner 
of its employment, in Bost. Med. and Surg: Jour., Feb. 10, 1876. 



476 NEW GROWTHS. 

disease often comes under notice. The lesions are of all sizes, 
from a pin-head to a split pea, are brownish red in color, and are 
covered with a layer of imperfectly formed epidermis. They are 
firm or soft, and are without pain. The patch now becomes more 
circumscribed and pronounced in outline. Having arrived at this 
stage of development, the process may terminate either in absorp- 
tion of the lesions, leaving a desquamative, atrophic, partially 
cicatricial tissue (lupus exfoliativus) ; or, in disintegration and 
complete destruction of the infiltrated skin, resulting in ulcera- 
tion and crusting (lupus exulcerexs, lupus exedens). If 
exuberant granulations spring up about the ulcer, the condition 
is known as LUPUS HYPEETBOPHICUS. Anderson* describes a 
form which he regards as distinct from the ordinary verrucous 
firms, and which he considers is entitled to be called "lupus 
verrucosus." It begins by the development of small, circum- 
scribed, dusky-red or violaceous patches or tubercles, which be- 
come covered with warty excrescences, which can be readily picked 
off, leaving a non-ulcerated surface with hypertrophied papillae. 

From the course of the disease as described, it will be .-ecu that 
the different forms are but modified stages of one process. It may 
be arrested at any period of its evolution, and in this manner con- 
stitute a variety of the disease. Not infrequently several or all 
of the lesions may be present at the same time, giving rise to a 
multiform picture in which the whole course of the affection may 
be studied. The disease in its early stages is unaccompanied by 
marked subjective symptoms; later, a variable amount of pain 
may be present. 

Jt has its seats of predilection; it appear- commonly about the 
face,t especially the nose, cheeks, and ears. It also frequently at- 
tacks the extremities, particularly the fingers, where it may be 
followed by serious deformity. The trunk may also be involved. 
It is a destructive process, wherever it occurs, occasioning exten- 
sive ulcers, ugly cicatrices, and at times much deformity. It does 
not confine its ravages to the skin, but may invade other tissues, 
as the mucous membrane and cartilage. The mouth, cartilages 
of the nose, ear, larynx, and even the eye, may be attacked. 

* Lectures on Clinical Medicine. London, 1879. 
f See Plate B B in my Atlas of Skin Diseases. 



LUPUS VULGARIS. 477 

Etiology. — The causes are obscure. It usually originates in 
childhood, generally making its appearance before puberty. It 
is never congenital. It is rarely, if ever, hereditary. It attacks 
both sexes in about like proportion. It is of much more frequent 
occurrence in some countries than in others. Thus, it is common 
in Germany, Austria, and France, less so in Ireland and England, 
and decidedly rare in the United States. It occurs here, according 
to the statistics of the American Dermatological Association, with 
about the same frequency as lupus erythematosus, 42 cases out of 
16,863 having been reported. It is rarer, I think, in this city 
than in New York. The majority of cases encountered in this 
country occur among the poor Irish and German population. 
The general health is found to vary. At times the subjects are 
debilitated, ill fed, and improperly cared for; other cases, how- 
ever, show no signs of poor health. It is not caused by syphilis. 
Both the history and the course of these diseases are different. 
In the majority of instances lupus and scrofuloderma are to be 
viewed clinically as distinct processes, the former being frequently 
encountered in cases to which the term scrofulosis would be in- 
applicable. In some cases, however, the disease seems to be a 
combination of both processes. 

Pathology. — The anatomy of this disease has been carefully 
studied by Virchow * and Auspitz,f and more recently by Lang,J 
Kaposi,§ Friedlander,|| Thoma,T[ Thin,** and Jarisch,ff with 
somewhat varying results, according to the different lesions and 
more particularly stages of the disease examined. Briefly stated, 
the process consists essentially of a chronic inflammation, charac- 
terized by a small, indifferent cell-infiltration, tending to develop 
in the form of aggregations, having its primary seat, as pointed 
out by Auspitz, in the corium. Kecently Kaposi || has again 

* Die Krankhaften Geschwiilste. 

f Die Zelleninfiltration der Lederhaut. Med. Jahrb., Wien, 1864. 

% Viertelj. fur Derm. u. Syph., 1874, Heft 2, pp. 165, 368 ; 1875, Heft 1, p. 
1. "Wiener Med. Jahrb., 1876, Heft 1 (see Viertelj., 1876, Heft 4, p. 603). 
Wiener Med. Presse, 1878, Nos. 6, 8 (see Viertelj., 1878, Heft 2, p. 346). 

g Loc. cit. 

|| Virchow's Archiv, Bd. lx. (1874). f Ibid., Bd. lxv. 

** Med.-Chir. Trans., vol. Ixii., 1879. 

ft Viertelj. fur Derm. u. Syph., 1880, Heft 1, p. 3. 

%% Path, und Ther. der Hautkrankheiten. Wien, 1880. 



4'8 NEW GROWTHS. 



expressed his views, and gives so clear an exposition of our pres- 
ent knowledge of the subject that I shall largely quote from 
his description. Under a low power, microscopic sections of 
deeply-seated, recent lupus nodules show variously sized, round- 
ish, nest-like masses of tissue irregularly dispersed through the 
lower part of the corium, the upper and papillary layers of which 
however, as well as the rete, according to Kaposi, appear normal! 
Under higher powers these foci, or nests, are usually seen to be 
sharply defined from the neighboring. healthy connective tissue 
which surrounds them in thick bundles. Their structure consists 
of a finely-branching net-work, plentifully supplied with large ves- 
sels. In the larger meshes of this net-work cells are embedded, 
containing numerous highly refracting nuclei, which stain well; 
while the smaller meshes contain in addition smaller cells, together 
with sharply contoured nuclei in large numbers. The embedded 
elements can sometimes be readily shaken out of the mesh-work 
leaving empty spaces behind in place of the foci of formed ele- 
ments. These appearances arc found only in recent nodules. 

Further development, as well as the retrogressive metamor- 
phosis occurring later, gives rise to very complicated changes in 
the lupus tissue and also in most of the elements of the cutis Ac- 
cording to recent observers, as Kaposi,* Lang,f Stilling,! Jarisch,§ 
and lh.n,|| the bloodvessels play the chief part in the genesis of 
the pathological tissue. The recent lesion presents a rapidly pro- 
liferating tissue, rich in vessels. When retrogressive metamor- 
phosis sets in, decreased vascularity of the centre of the nodule 
occurs, and the formed elements undergo necrobiotic change 
The elements are cither absorbed, or, in superficial situations, are 
thrown off, the invaded cutaneous tissues undergoing cicatricial 
contraction. A part of the lupus tissue, however, undergoes or- 
ganization into young and later coarse connective tissue; and 
herein, according to Kaposi, lies the essential difference between 
lupus and lepra and syphilis. Lang! also holds the same view. 
Here and there the so-called "giant cells" of Schiippel ** and 

* ^° C - cit t Wien. Med. Presse, 1878, Nob. 6, 8. 

t Deutsche Zeitsehr. fur Chir., Bd. viii. p. 72. 

§ Viertelj. fur Derm. u. Syph., 1880, VII. Jahr"., p 3 

|| Loc. eit. «[ Viertelj. fur Derm. u. Syph., 1875, Heft 1, p. 1. 

** Untersuchungen uber Lymphdrusen-Tuberculose. Tubingen 1871 



LUPUS VULGARIS. 479 

Friedlander* appear. These are large, circular, ovalish, or ir- 
regular, well-defined, homogeneous or finely granular masses con- 
taining numerous oblong refractive nuclei. They were formerly 
believed to be characteristic of tubercle, but are now known to 
occur in various tissues and growths. 

While some lesions are undergoing the changes above described, 
others extend in various directions, unite, and give rise to a dif- 
fuse cell-infiltration, involving all the tissues of the skin, and 
finally ending, as a rule, in cicatricial contraction. When the 
lupus process has gone on for some years, a general hypertrophy 
of the tissues resembling elephantiasis may result. In some cases 
the papillae become highly developed and verrucous in character, 
constituting lupus hypertrophieus. 

The epithelial structures of the skin, according to Kaposi, are 
involved at an early stage of the process. Cell proliferation and 
degeneration take place in the rete, the boundary-line between the 
papillary and mucous layers being merged by the penetration of 
the lupus infiltration into the latter. When the rete is destroyed 
by suppuration or desquamation, the lupus lesions are exposed and 
ulceration occurs. The sweat and sebaceous glands are involved 
and suffer with the other tissues ; also the hair-follicles, resulting 
in loss of the hair. The ducts of the glands being destroyed, the 
acini frequently form epithelial globes or nests, or milium-like 
bodies resembling pearls embedded in the skin. Occasionally 
epithelial hyperplasia takes place, the epithelium of the rete grow- 
ing down in prolongations into the corium, and then,' joining 
similar processes from the glands and follicles, spaces are found 
enclosed by pure epithelium, which may become a histological 
basis for the development of epithelioma. The combination of 
lupus and epithelioma has been described by various writers, 
notably by Langf and Kaposi. J 

Diagnosis. — Lupus vulgaris is to be distinguished from syphilis, 
the disease with which it is most liable to be confounded, by at- 
tention to the papules, tubercles, ulcers, crusts, history, and course 
of the affection. The ulcerative stages most closely resemble each 



* Loc. cit. 

f Viertelj. fiir Derm. u. Syph., 1874, Heft 2, p. 165. 

$ Ibid., 1879, Heft 1, p. 73. 



480 NEW GROWTHS. 

other. The ulcers of lupus are, in the majority of cases, compara- 
tively superficial ; those of syphilis are ordinarily deep, and often 
have an excavated appearance. The ulcer of lupus is usually less 
extensive than that of syphilis. In lupus, moreover, there are, as 
a rule, a number of points of ulceration, which incline to become 
confluent, whereas in syphilis if several exist they usually remain 
separate and distinct. The'border of the syphilitic ulcer is sharply 
defined ; that of lupus is not apt to be so. The secretion of the 
syphilitic ulcer is generally copious, and offensive in odor; in 
lupus the discharge is usually slight, and inoffensive. The crusts 
of lupus are generally scanty, and reddish brown in color; those 
of syphilis are bulky, and are frequently greenish. The histories 
of the diseases are altogether unlike; lupus is very slow in its 
course, while syphilis is comparatively rapid. A month or six 
weeks is often sufficient to produce the characteristic ulcer of 
syphilis ; months <>r years would in all probability be required to 
bring about the same amount of destruction in lupus. If the case 
be one of syphilis, other symptoms of this disease will almost 
always be present. The cicatrices of lupus are generally distorted, 
hard, shrunken, and yellowish ; in syphilis they arc sottish and 
whitish, and are not apt to be particularly disfiguring, considering 
the amount of ulceration which has preceded. 

Lupus should not be confounded with epithelioma. As stated, 
they may appear together, but this occurrence is rare. The locali- 
zation of this disease, its usually painful character, and its seat, 
together with the circumscribed induration of the lesion, will in 
most cases serve for the diagnosis. In the ulcerative stages, how- 
ever, the diseases may resemble each other. The destructive ten- 
dency of epithelioma is notable, the loss of substance being seldom 
so great in lupus. The ulceration of epithelioma starts from a 
point and usually increases peripherally; that of lupus begins 
generally at many points within the patch. The hard, everted 
border of epithelioma is rarely, if ever, seen in lupus. The 
epitheliomatous ulcer is usually deep, with an uneven base, while 
that of lupus is more or less superficial, with a reddish base of 
fine granulation tissue. The course of epithelioma is, as a rule, 
more rapid than that of lupus. Epithelioma seldom occur- in 
the young; lupus usually begins in childhood. 

Lupus erythematosus is never accompanied by ulceration, and 



LUPUS VULGARIS. 481 

the absence of this feature will always enable this disease to be 
diagnosed from lupus vulgaris. The patches in lupus erythema- 
tosus are superficial, uniformly reddish in color, and covered 
with adherent, grayish or yellowish scales. They are, moreover, 
circumscribed, and are without papules or tubercles. The seba- 
ceous glands and follicles are generally markedly involved in 
lupus erythematosus, which is not the case in lupus vulgaris. 
The age at which the diseases usually first appear is also to be 
remembered. Acne rosacea at times bears some resemblance to 
lupus vulgaris, but may readily be distinguished by its dilated 
vessels, color, the presence of acne pustules, history, and course. 

Treatment. — Lupus vulgaris is one of the most obstinate of 
all cutaneous diseases. It seldom yields except under the most 
determined measures. It is, however, I think, somewhat more 
amenable to treatment, especially constitutional treatment, in this 
country than abroad. In Austria the disease, it would seem, 
defies such remedies. The general condition of the patient is to 
be inquired into. The age, past history, mode of life, and present 
state, as regards both the extent of the disease and health, should 
all receive attention. Hygienic influences should be considered. 
The digestive tract should be kept in order, the bowels and other 
functions regulated, and every means employed to promote health. 
The diet is likewise of importance. It should consist of the most 
nutritious articles of food. Cod-liver oil is certainly one of the 
most valuable remedies, and should be freely administered for a 
long period. Iodide of potassium is of almost equal value. In 
some cases I have found it to succeed admirably; its influence 
should always be tested before severe external remedies are 
resorted to. Liveing recommends a mixture containing one 
fluidrachm syrup of the iodide of iron; three minims tincture 
of iodine ; and five grains iodide of potassium. Iodine and 
phosphorus may also be advantageously employed, especially in 
combination with cod-liver oil. According to Neumann, sulphur 
baths are sometimes highly beneficial. 

External remedies, however, are, in the majority of cases, more 
important than internal treatment. A number of preparations, 
most of them of a caustic nature, have been recommended. They 
should be selected to suit the particular stage and variety of the 
disease. The amount of surface and the region of the body in- 
31 



482 NEW GROWTHS. 

volved are also to be taken into consideration. In the earlier 
stages stimulating applications may be employed with a view to 
bring about absorption ; equal parts of tincture of iodine and 
glycerine, painted over the part, mercurial plaster, tar, and oint- 
ment of the red iodide of mercury, may be used for this purpose. 
In the non-ulcerative forms oil of cashew-nut is recommended 
by Vidal,* applied with friction every three or four days. Caus- 
tics are, however, necessary in the majority of cases. Of these, 
potassa, nitrate of silver, arsenic, pyrogallic acid, carbolic acid, 
acetate of zinc, red iodide and red sulphuret of mercury, and 
chloride of zinc, either alone or in various combinations, are the 
most valuable. 

Potassa may be used where a powerful effect is required, but it 
should always be handled with care. In stick form it may be 
applied to tubercles and hypertrophic conditions which require 
destruction. A solution of potassa, one or two drachms to the 
ounce, is also of service, applied by means of a charpie brush. 
The operation is severe, although the pain does not continue long, 
ceasing upon neutralization of the alkali with acetic acid, which 
should invariably be applied immediately after the cauterization. 

Nitrate of silver, in stick form or in solution, equal parts with 
water, constitutes one of the best caustics, and may be employed 
without danger of leaving scars. It never penetrates deeply. 
Papules and tubercles may be disturbed by boring into them with 
the solid stick, while patches are most successfully treated with the 
solution, repeatedly applied with the charpie brush. It is the 
mildest and safest of the caustics, and should therefore be em- 
ployed about the region of the nice, where cicatrization is to "be 
guarded against. 

Arsenic has long been used. It possesses the advantage that 
when applied to a part it destroys only the diseased tissue, leaving 
the healthy skin intact; but it is a painful application. Cosme's 
paste, as modified by Hebra, is the best method of employing it : 

R Acidi Arseniosi, ^i ; 

Hvdrarg. Sulphuret. Rub., ^i ; 

Ungt. Simplicis, gi. 
Ml Ft. ungt. 

* Gazette des Hopitaux, No. 35, 1879. 



LUPUS VULGAEIS. 483 

This is to be spread thick on a piece of cloth, and applied closely 
to the patch for two or three consecutive days, until the lupus 
nodules and points are blackish and destroyed. On the second 
and third days the pain is apt to be severe. The results, how- 
ever, are at times satisfactory. Pyrogallic acid is also a particu- 
larly valuable remedy, somewhat analogous in its action to arsenic, 
though less severe, and may be used in the form of an ointment 
in the strength of one or two drachms to the ounce. It is com- 
paratively painless. 

Carbolic acid has been repeatedly tried, but with indifferent 
success; it acts superficially and produces considerable pain. Ace- 
tate of zinc, well spoken of by Neligan, and more recently by 
Weisse,* may be applied in the form of the crystal. Its' use should 
be repeated from week to week until cicatrization takes place. The 
pain is said to be severe at the time, but not to continue ; it may 
be relieved by the use of water. An ointment composed of equal 
parts of the red iodide of mercury and simple ointment, applied 
upon a piece of cloth, is used frequently by Hardy ; it produces 
a caustic effect, with discharge, at the expiration of from six to 
twelve hours, followed by a crust. 

Chloride of zinc may be used as a paste, as in the following 
formula, proposed by Hebra: Equal parts of chloride of zinc and 
chloride of antimony, with sufficient strong hydrochloric acid to 
dissolve the chloride of zinc. They are to be rubbed up with 
enough powdered liquorice root to make a paste, and spread upon 
a piece of cloth and applied while still moist. It should be per- 
mitted to remain on twenty-four hours, when an eschar will have 
formed. It is a strong caustic, and should be applied only when 
it is desirable to destroy the whole patch, for it acts upon healthy 
as well as upon diseased skin. Vienna paste, consisting of equal 
parts of potassa and lime, may be recommended for a similar pur- 
pose. It is to be made into a paste with alcohol at the time it is 
used, and applied upon a cloth for five or ten minutes; it destroys 
everything with which it comes in contact, producing a blackish 
eschar. The action of the caustic should be arrested with acetic 
acid, and the surface dressed with a water compress or with simple 
ointment. When either of the two latter preparations is employed, 

* Amer. Jour, of Syph. and Derm., Oct. 1870. 



484 NEW GEOWTHS. 

the skin surrounding the patch should be protected with strips 
of plaster. 

The treatment of the disease by erasion, or scraping with 
the dermal curette, or scraping spoon, according to the method 
devised by Volkmann,* has proved very successful, and may be 
regarded as a most valuable remedial measure. The instrument 
used is a small, round or oval metallic spoon or scoop with sharp 
edges. Various shapes and sizes will be found useful, according 
to the case and the tissue to be attacked. f The disease, after being 
frozen, is scraped away or dug out until the base of the wound is 
found to be sound. The operation should always be thorough. 
The scar, as a rule, is soft and smooth and less disfiguring than that 
which follows caustics. If the disease be extensive or painful, the 
patient should be etherized. Where difficulty is experienced in 
destroying the disease by erasion, this process may be supplemented 
by the use of caustics, as, for example, pyrogallic acid, arsenic, 
or chloride of zinc, or by the galvano-cautery. Both the actual 
cautery and the galvano-cautery have been used by Hebra, and 
arc recommended, especially the latter, by Neumann, Kaposi, and 
Piflard. Sharp-pointed cylindrical or knife-shaped instruments 
may be employed, or, in some cases, the wire loop. The operation 
is nut very painful. Neumann J figures a convenient instrument 
for the purpose. Where much destruction of tissue is demanded, 
Paquelin's thermo-cautery may be used with advantage. 

The treatment by multiple puncture or scarification is also of 
great value, the object being to set up a traumatic inflammation, 
under which the disease heal-. Balmanno Squire § ha- devised a 
method of multiple linear scarification by means of a many-bladed 
knife. The tissues are first frozen, by means of a mixture of ice 
and salt or by the use of an atomizer with rhigoline, and a num- 
ber of parallel incisions made through the lupus tissue, followed 



* Sammlung Klinische Vortrage, No. 13. Leipzig, 1870. 

f They may be obtained from any of the instrument-makers, among whom 
I may mention J. H. Gemrig & Sons, of this city, Tiemann & Co., of New 
York, and John Weiss & Son, of London. 

J Lehrbuch der Hautkrankheiten, oter Auflage. TVien, 1880, p. 403. 

I Trans, of the Brit. Med. Assoc. Arch, of Derm., 1879, p. 413. See also 
an article favorable to this method of operation, by Tidal, in the Annales de 
Derm, et de Syph., Jan. 1880, p. 144 ; also Arch, of Derm., Oct. 1879, p. 425. 



SCROFULODERMA. . 485 

by similar scarifications in a direction transverse to the first. The 
bleeding is slight, and the pain passes away in the course of an 
hour or two. If active inflammation be set up, cold compresses 
may be used. Multiple puncture by means of sharp-pointed in- 
struments charged with iodized glycerine has also been used by 
Auspitz* and others. Schifff suggests a rubber pipette to which 
is attached a hypodermic syringe needle ; this being charged with 
the caustic solution, the point of the needle can be introduced into 
the lupus nodule and a single drop of the caustic injected exactly 
at the desired point. 

Prognosis. — This will depend upon the form of the disease, its 
duration, the age of the patient, and the extent of surface involved. 
The disease runs an exceedingly stubborn and chronic course. If 
it be confined to one patch or region, a more favorable termination 
may be anticipated. The thoroughness of the external treatment 
must also influence the prognosis. The deformity attending and 
following the disease, in the form of hard scars and contraction 
of the joints, is usually marked. 

SCROFULODERMA. 

Symptoms. — Under the name scrofuloderma I would include 
those morbid conditions of the skin which exist as an expression 
of the peculiar state of the system designated scrofula, scrofu- 
losis, or struma. The cutaneous lesions vary materially, but are 
nevertheless in most cases characterized by certain general features 
which serve to distinguish them from other diseases. As a rule, 
the affection begins in one or more of the lymphatic glands, which 
become swollen and permanently enlarged, constituting firm, 
roundish or oval tumors, unattended in the beginning by redness 
or pain. They increase in size slowly. Having attained certain 
dimensions, as, for example, the size of an almond, they may 
either remain in this state, or, as is usually the case, undergo soft- 
ening. The skin covering them becomes hyperaemic, chronically 
inflamed, of a violaceous hue, and by degrees thin and sensitive. 

In the course of time, ordinarily months, fluctuation is expe- 

* TTeber die Mechanische Behandlung der Hautkrankheiten. Viertelj. fur 
Derm. u. Syph., III. Jahrg., 1876, p. 562. A valuable article, 
f Viertelj. fur Derm. u. Syph , VII. Jahrg., 1880. 



486 NEW GROWTHS. 

rienced, and the tumor breaks open, giving forth a discharge, 
composed of pus, blood, serum, and a whitish or yellowish, flaky., 
caseous matter. The character of the fluid varies, being at times 
puriform, in other cases thin and watery. The discharge usually 
continues oozing more or less for an indefinite period. Sinuses 
are apt to form, which often burrow deeply and invade the ad- 
jacent tissues. The condition is now chronic, and may remain, 
becoming better and worse from time to time, for months or years. 
Sooner or later, however, the glands break down completely, termi- 
nating in ulcers, the tendency of the disease being to ulceration 
and cicatrization. 

The ulcers vary as to their size, shape, depth, and general fea- 
tures, according to their seat and other circumstances. They are 
usually elongated or almond-shaped, with irregular, thin, more or 
less undermined, pale-red or violaceous edges. Their base- are 
uneven, and are usually studded with unhealthy-looking, pale, 
flabby granulations. They incline to bleed easily. According to 
the amount of secretion and its nature will the crusting be slight 
or extensive, but, as a rule, it is inconsiderable. The crust may be 
cither brownish or grayish in color, and is usually thin and ad- 
herent; when removed, the ulcer is apt to bleed. The scrofulous 
ulcer manifests no disposition to heal. Its course is chronic. The 
reparative process i- always -low. As a rule, it is not painful. 
The scar is generally of a hard, irregularly contracted, knotty 
character. 

The disease is most often met with about the face, beneath the 
lower jaw, and around the neck. A variety of concomitant symp- 
toms, indicative of the scrofulous state, usually accompany the 
cutaneous manifestation. Chronic inflammatory affections of the 
eyes, discharge from the cars, and coryza are -at times present, 
particularly in children. In other cases, swellings of the joints 
and enlargement of the bones are observed. The skin generally 
has a pale, yellowish appearance, and is soft and flabby, and at 
times puffed. Old scars, the result of previous disease, may often 
be detected in one or another region. 

In place of the lesions just described, which constitute the 
usual cutaneous manifestations, there may develop other and rarer 
varieties of the disease, which may be referred to. The disease 
sometimes manifests itself by the formation of variously sized, 



SCEOFULODEEMA. 487 

often large, rounded, ovalish, or irregularly shaped, yellowish, flat 
pustules, with a deep-red or violaceous areola. The crust forms 
slowly, beginning in the central portion of the pustule, and may 
be complete or partial. It is usually flat and scanty, differing in 
this respect from the similar syphilitic lesion. It is brownish and 
adherent, and when raised shows an ulcer with the general char- 
acters described as belonging to the scrofulous ulcer. One, two, 
or more lesions may exist. They may appear upon any region. 
They pursue a chronic course, and are followed by marked, soft, 
and comparatively superficial scars. 

Another and rarer scrofulous manifestation is characterized by 
the formation of one or more variously sized, irregularly shaped, 
ill-defined, papillary, verrucous, or fungoid growths. Their color 
is a pale, bright, dusky, or violaceous red. The surface is exco- 
riated or ulcerated, and often shows yellowish, punctiform or fo- 
raminous lesions, accompanied by discharge and crusting. Such 
formations are met with usually on the hands, and are accompanied 
ultimately by deformity, resulting from deep-seated and sometimes 
bone changes. Their course is eminently chronic. The disease 
resembles the verrucous or hypertrophic variety of lupus vulgaris. 

Another variety of disease, which I have elsewhere * described 
at length, and which for the present may be viewed as a manifes- 
tation of scrofulosis, consists in the formation of pin-head and 
small split-pea sized, disseminated, yellowish, flat pustules, with 
usually a raised, violaceous areola. In general appearance the 
lesions resemble those of the small pustular syphiloderm. They 
crust over gradually, in the course of from one to several weeks, with 
depressed, shrunken, hard or horny, yellowish or grayish, adherent 
crusts, which in time drop off, leaving marked, punched- out-look- 
ing, indelible scars, resembling those of variola. The lesions are 
further characterized by a sluggish, chronic course, and may last 
weeks or months. They appear at irregular periods, new ones 
coming out as the older ones disappear, so that the patient is rarely 
free of them. The disease may continue for years. It may occur 
upon any region, but in the cases that I have encountered it has 
shown a disposition to appear about the face and on the extremi- 
ties. Other symptoms of scrofulosis are sometimes present. 

* Amer. Jour, of Med. Sci., Oct. 1881. 



488 NEW GROWTHS. 

Etiology. — It may be inherited or acquired, but it is usually in- 
herited, frequently arising from the marriage of blood relations. 
The causes which are recognized as being capable of producing 
the disease during life are insufficient and unwholesome food, and 
depressing external influences of all kinds, as, for example, long 
residence in cold and wet climates, impure air, damp and dark 
dwellings, want of exercise, and the like. It is also known to 
follow certain diseases, as, for example, measles and scarlatina, and 
perhaps remotely, in the third or fourth generation, syphilis. It 
is apt to show itself first in early childhood. It is more common 
in the colored than in the white race, and is particularly prone to 
attack mulattoes. It is not contagious. The nature of the disease 
is still involved in obscurity. The question of the relation of 
scrofula and syphilis to lupus has again been brought forward by 
Kaposi* and by Auspitz.f The latter gives to lupus a broader 
clinical significance than most authors. He applies the name to 
a group of symptoms which develop upon the anatomical basis of 
a granuloma, as described by Virchow, and are characterized clin- 
ically by the persistence, continuous relapse, and slow degenera- 
tion of their nodular, flattened, and often serpiginous forms of 
eruption, which sometimes are scaly, in other cases ulcerate, and 
sometimes atrophy into cicatrices without ulceration. Under this 
definition he believe that certain forms of inveterate and hereditary 
syphilis may be properly called syphilitic lupus, the same holding 
true of scrofula. 

Diagnosis. — It is to be distinguished from lupus vulgaris and 
from syphilis by the presence of the concomitant general symptoms 
of scrofulosis, and by the peculiar features of the lesions, which 
in the majority of cases differ materially from those of lupus 
vulgaris and syphilis. 

Treatment. — The treatment must be directed against the general 
disease. The internal remedies of service arc the preparations 
of iron, iodine, and sulphur, phosphorus, lime, and cod-liver oil. 



* Ueber den sogenannten Lupus Syphiliticus. Wiener Med. Wochenschr., 
1877, Nos 50, 51, 52. 

f Ueber Lupus Syphiliticus und Serophulosis. Wiener Med. Presse, Nos. 
3, 4, 1878. See an abstract of the article, by Dr. J. C. White, in Bost. Med. 
and Surg. Jour., June 20, 1878. 



SCROFULODERMA. 489 

According to Harkin* and Shoemaker, f chlorate of potassium is 
also a valuable remedy. Sea air and attention to hygiene are both 
of importance. The diet should be generous, and should con- 
sist largely of animal food. Locally, the ulcers are to be treated 
by stimulating ointments, the mercurial preparations being the 
most reliable. Lotions are likewise useful, corrosive sublimate 
and alcohol, from a quarter of a grain to a grain to the ounce, 
and yellow-wash, constituting valuable applications. Tincture 
of iodine, diluted, and the solution of chlorinated soda may both 
be used with benefit. The curette is also of great value here, as 
in lupus vulgaris. 

Tuberculosis of the Skin. — The existence of tuberculous 
ulceration of the skin has long been disputed, but Chiari| reports 
five or six cases, all occurring upon the lips, and in one case the 
anus also, which seem to be entitled to this designation. Jarisch§ 
has also reported a case in which the ulceration occurred about the 
ear and in the mucous membrane of the oral cavity. The ulcers 
are roundish, ovalish, or (as in Jarisch's case) serpiginous, with ir- 
regular, gnaw r ed, bright-red, swollen, moderately infiltrated edges, 
the ulcerating surface being granular and of a reddish-yellow color. 
The secretion is thin and scanty. They do not bleed easily when 
handled. When they occur on the mucous membranes, they show 
small, pin-head sized, yellowish papular lesions in the neighbor- 
hood. The disease is invariably found in tuberculous subjects, 
and runs a comparatively rapid course. It is very rare. Chiari 
examined the bodies of six thousand patients, sixty per cent, of 
whom had died of tuberculosis, and encountered the tuberculous 
ulcer in only five instances. 

Microscopic examination shows infiltration of the tissues beneath 
and about the ulcer, with numerous lymphoid cells, interspersed 
here and there with small, isolated or aggregated, rounded nod- 
ules (true miliary tubercles), some of which are superficial and 
correspond with yellowish lesions on the surface of the sore. 

* Dublin Quar. Jour, of Med. Sci., Nov. 1861, and May and Nov. 1880. 
f Trans. Amer. Med. Assoc, 1880; Med. Bull., Sept. 1880. 
X Wien. Med. Jahrb., 1877, Heft 3, p. 328, and Viertelj. fur Derm. u. Syph., 
VI. Jahrg., 1879, p. 269. 
I Ibid., p. 265. 



490 NEW GllOWTHS. 

The nodules are composed of small rounded cells, and are often 
found broken down in their centre and undergoing cheesy de- 
generation. 

Mention may here be made of the disease which is known as 

PODELCOMA, FUNGUS FOOT OF INDIA, MADURA FOOT, and MY- 
CETOMA. It is characterized by swelling of the affected part — 
usually the foot, although the hand or other regions may be in- 
vaded — and the formation of pea sized, soft, tubercular lesions 
which are studded with masses of minute blackish grains resem- 
bling fish-roe, which ooze from sinuses leading from the interior 
of the affected part. The disease is encountered chiefly in India, 
and has been studied by Vandyke Carter* and Lewis and Cun- 
ningham;! Dut it also occurs in this country, as in the following 
case reported by Kemper.| The patient was a young man, an 
American by birth, whose foot six months before became red- 
dened, swollen, and painful, followed in a few weeks by extreme 
tenderness of the sole with blebs, which were succeeded by open- 
ings from which oozed a glairy fluid resembling the white of an 
egg. Ulcers formed later, which were covered with a whitish, 
finny substance like mould, and which were found to be the 
openings of deep-burrowing sinuses. On account of the great 
pain, amputation was ultimately performed, when portions of the 
muscles were discovered to be disintegrated and to contain masses 
of a mould-like material which under the microscope with two 
hundred diameters was seen to be composed of numerous granu- 
lated, rough, irregularly-shaped, yellowish, refractive bodies, which 
Dr. Kemper regarded as vegetable spores. The disease has never, 
I believe, before been described as occurring in this country. Its 
exact nature does not seem to be positively established. It is 
questionable whether it is due to fungus. 

In this connection reference may also be made to ainhum, a 
disease peculiar to the African race, which has been described by 
Silva Lima, of Bahia.§ It is characterized by a slow, progressive, 

* On Mycetoma. London, 1874. 

f The Fungus-Disease of India. Calcutta, 187-5. 

X Amer. Practitioner. Sept. 1876. 

\ Arch, of Derm., Oct. 1880. 



AINHUM. 491 

fatty degeneration, generally with increase in volume of the toes, 
especially of the smallest, involving almost all of their anatomical 
elements, resulting from a nearly linear strangulation, occasioned 
by the presence of a narrow strip of contracted and hardened skin. 
,This embraces at first a part and afterwards the whole of the cir- 
cumference of the toe, at the digito-plantar fold. The constriction, 
after from four to ten years, forms a deep circular furrow, which 
determines the absorption of the phalanges, the obliteration of 
the vessels, and the inevitable dropping off of the toe. The dis- 
ease is said to be common on the west coast of Africa, and is also 
met with in certain Indian tribes in Asia. In South America it is 
encountered in Bahia, Rio de Janeiro, and Buenos Ayres. Cases 
have been encountered in North Carolina, reported by Drs. Horn- 
aday and Pittmann.* 

The disease known under the title of perforating- ulcer of 
the foot, and on the continent and especially in France as mal 
perforant DU pied, may also be referred to. According to 
Savory and Butlin,f who have published a valuable article on the 
subject, the lesion is not accurately described by the term ulcer. 
It varies in character, but is usually characterized by a small aper- 
ture, like the orifice of a sinus, in the centre of a large corn, which 
leads directly down by a narrow channel to exposed and diseased 
bone. Sometimes there are granulations around the orifice. There 
is little or no discharge, and in all respects the lesion is indolent. 
There is no pain, scarcely any even upon pressure. There is usually 
anassthesia of the region, with reduced temperature, and a tendency 
to profuse perspiration. 

The ulcer is usually seated over the articulation of the meta- 
tarsal bone with the phalanx, generally over that of the first or 
the last toe. There may be more than one, and both feet may be 
affected. The disease, according to Savory and Butlin, is the result 
of pressure, or violence, or injury to structures whose nutrition is 
impaired or whose vitality is defective from disease or degeneration 
of the supplying nerves. The lesion is rebellious to treatment, 



* North Carolina Med. Jour., Sept. 1881. 

f Med.-Chir. Trans., vol. Ixii., 1879 (with a chromo-lithograph, microscopic 
drawings, and a bibliography). 



492 NEW GROWTHS. 

usually recurring after operation or even amputation of a toe or a 
portion of the foot. The use of au artificial leg may be resorted 
to, thus giving the part complete rest. 

LEPRA. 

Sy?i., Elephantiasis Graacorum ; Lepra Arabum ; Leontiasis; Satyriasis; 
Leprosy; Germ., Der Aussatz ; Fr., La Lepre ; Norwegian, Spedalskhed. 

Lepra is an endemic, chronic, malignant, constitutional 
disease, characterized by alterations in the cutaneous, 
nerve, and bone structures, resulting in anaesthesia, ulcer- 
ation, necrosis, general atrophy, and deformity. 

Symptoms. — The disease is a constitutional one, and involves 
the whole organism most profoundly. It exhibits its presence 
by both general and local symptoms of a marked character. Its 
invasion is usually slow and insidious, years often elapsing before 
it becomes pronounced. Premonitory symptoms, consisting of 
malaise, mental depression, languor, sleepiness, loss of appetite, 
nausea, chills, repeated attacks of fever, general debility, nervous 
prostration, and pains in the bones, are present in the majority of 
cases. These may be severe or slight, and may continue for weeks, 
months, or years without other Bymptoms. Sooner or later, how- 
ever, more characteristic features manifest themselves, prominent 
among which are the lesions of the skin. These, like the earlier 
symptoms, vary in form; they may be either bullous, macular, pig- 
mentary, or tubercular. They may appear separately, following 
one another in succession, or, as not infrequently happens, several 
or all of them may be present at the same time. The cutaneous 
manifestations, like those of syphilis, are remarkable for their mul- 
tiformity. They also vary exceedingly as regards the degree of 
their development; at times they constitute the principal symp- 
toms of the disease, while in other eases they are subordinate to 
the lesions of other tissues. Various organs of the body are, sooner 
or later, influenced by the disease, particularly the nerves. It will 
thus be seen that the manifestations upon the skin represent but 
one phase of a serious and malignant systemic disorder. 

Two forms of leprosy are recognized, the tubercular and the 
anaesthetic. Xo absolute line, however, separates the one variety 
from the other. Although the symptoms of each are generally 



LEPRA. 493 

well marked, they not infrequently appear simultaneously upon 
different parts of the body. 'One variety may, moreover, pass 
into the other. From these remarks it will be understood that 
the manifestations of either form of the disease are liable to vary 
considerably. 

Lepra Tuberculosa — Tubercular Leprosy. — As the 
name indicates, this variety is attended chiefly by the formation 
of masses of infiltration and tubercles ; together with these, how- 
ever, are found other lesions, at times almost as prominent in 
character as the tubercles. An eruption of blebs, similar to those 
observed in pemphigus, usually constitutes one of the first cuta- 
neous manifestations. These may show themselves irregularly for 
some time before other more definite symptoms appear. It is 
said that they more frequently precede the anaesthetic than the 
tubercular form of the disease. Macules now make their appear- 
ance as smooth, shining, erythematous patches (lepra macu- 
losa). They are usually defined, and consist of circumscribed 
areas of infiltration ; in other cases they are not surrounded by 
any line of demarcation, but fade into the healthy tissues. They 
are usually upon a level with the skin, but they may be some- 
what raised. In color they are yellowish or reddish, assuming 
usually a dusky yellowish or brownish hue as they grow older. 
Not rarely they are pale-yellowish in color, and have the appear- 
ance of a firm, fatty, lardaceous deposit. They are aptly likened 
to a piece of cut, raw bacon, inserted in the skin, and are gen- 
erally surrounded by a delicate pinkish or lilac border, which 
upon close inspection is seen to be made up of a minute plexus 
of bloodvessels. The sensibility is materially altered from the 
first, and is found to vary between hyperesthesia and complete 
anaesthesia; at first they are usually hyperaesthetic, while later 
they become markedly anaesthetic. They may appear upon any 
part of the body, although their most common seat is upon the 
trunk and extensor surfaces of the extremities ; not rarely they 
are present in such numbers as to involve a considerable surface 
of the body. Their course is variable ; they may disappear and 
reappear from time to time, or they may remain as permanent 
lesions, in which case they increase in size. 

Sooner or later the disease manifests itself in the form of 
variously shaped and sized nodules and tubercles, which may 



494 NEW GROWTHS. 

assume the definite outline of tubercles, or develop into irregu- 
larly-shaped prominences and elevated masses (lepra tuberosa). 
When typical, they are roundish in form and of all sizes from 
a cherry to a walnut, or even larger. They may either stand 
forth conspicuously Or be but slightly raised. They have a 
yellowish, brownish, or bronzed color. Their seat is in the skin 
and subcutaneous tissues. They are more or less painful when 
pressed upon. They manifest themselves upon all regions of the 
body, but generally form in greatest numbers about the face, 
the forehead, eyebrows, cheeks, nose, lips, chin, and ears being 
favorite localities. The other portions of the body, notably the 
trunk, buttocks, arms and legs, fingers and toes, are likewise 
often invaded. 

The deformity which these tubercular or nodular masses occa- 
sion is striking. When they occur about the face, the features 
become horribly distorted. The tissues appear more or less swollen 
and infiltrated, while the skin is here and there thickened, puffed 
out, and moulded into unsightly shapes. The natural lines of 
the surface are exaggerated, and give a heavy expression to the 
face. The skin of the forehead and eyebrows is usually markedly 
thickened and corrugated, and stands out in bold prominences, 
suggesting a likeness to the head of the lion (leontiasis). The 
Dose, cheeks, and mouth are also often the seal of extensive in- 
filtrations. Later in the course of the disease the tubercles ap- 
pear upon the mucous membrane of the mouth, extending into 
the various passages, attacking the pharynx, epiglottis, larynx, 
and Dares. The eye also suffers. 

The course of the tubercle varies. It may last for a long period 
without undergoing much change, or, on the other hand, it may at 
once pass into softening and ulceration; or it may disappear by 
absorption. Ulceration occurs for the most part about the fingers 
and toes, the ulcers being covered with adherent, brownish crusts. 

Lepra Anjesthetica — Anaesthetic Leprosy. — This va- 
riety may appear either in conjunction with the tubercular form 
or alone, in which case it is characterized by the presence of a 
number of symptoms in addition to the anaesthesia. Frequently 
one of the first symptoms encountered is an eruption of blebs, 
which appear in an irregular manner, coming out from time to 
time, followed by pigmentation. They may continue to show 



LEPRA. 495 

themselves for an indefinite period, after which anaesthesia is no- 
ticed about their former seat. In other cases the macules referred 
to in describing the tubercular form constitute the earlier symp- 
toms. Hyperaesthesia of the skin is also one of the early signs of 
the disease, the patient complaining of pains and burning sensa- 
tions, which are usually succeeded by anaesthesia, affecting either 
a limited portion or the greater part of the surface. The macular 
patches are anaesthetic, often to such an extent that a pin may be 
thrust into and through them without causing pain. Later, por- 
tions of the skin free of macules become in like manner anaes- 
thetic. The skin now frequently assumes an atrophic condition, 
being dry, yellowish or brownish in color, and more or less 
wrinkled. 

Following this alteration in the structure of the skin, the sub- 
cutaneous tissues and muscles undergo atrophy, giving rise to de- 
formity, especially of the fingers and toes. The hair and nails 
also show the same change, and are either altered in their struc- 
ture or are completely cast off. The hands and feet, suffer most 
seriously, and are subject to great mutilation. The fingers and 
toes become bent, crooked, and contracted. Sooner or later the 
bones are attacked, causing destruction of the joints and of the 
bones themselves. The skin over the joints becomes excoriated 
and ulcerated, the ends of the bones undergo disintegration, and 
the phalanges finally either become absorbed or drop off. Not 
only fingers and toes but also hands and feet may gradually be 
lost. The extremities become more or less completely anaesthetic, 
and are greatly wasted, at times to half their former size (lepra 
mutilans). 

Etiology. — The causes of the disease, notwithstanding the ef- 
forts that have been made to elucidate them, still remain obscure. 
A multitude of facts, however, of extreme interest have been 
brought together, from which valuable information has been de- 
duced. Leprosy has existed from time immemorial, quite accu- 
rate descriptions of it being found in the writings of the ancients. 
At the present time the disease, existing endemically, is limited to 
certain geographical districts, which, however, embrace an extensive 
tract of territory, as may be seen by the following enumeration of 
the countries. It exists in Africa, along the shores of the Medi- 
terranean and of the Atlantic and Indian Oceans, as well as in the 



496 NEW GROWTHS. 

interior of the country ; also in Asia Minor, Arabia, Persia, India, 
China, Japan, Kamtschatka, the various islands of the Pacific 
Ocean, and Australia. According to returns made in 1872, there 
were 99,000 lepers in the territories of India.* In Europe, it 
is found in Norway, Southern Spain, Sicily, Greece, and South- 
ern Russia. Upon the western hemisphere it occurs in Mexico, 
Central America, in the islands of the West Indies, along the 
coast of South America, and especially in Brazil. It also exists 
to some extent in the island of Iceland. The disease also prevails 
to a large extent in the Sandwich Islands, Chinese emigrants, it 
is said, being responsible for its introduction upon these islands. 
According to Piffard,| forty years ago the disease did not exist 
there : now one-tenth of the inhabitants are lepers. The disease 
is likewise found to some extent in the United States. Cases have 
been encountered in some of our Southern and Western States, 
especially Louisiana and South Carolina. Prof. Jones J reports 
sixteen cases in Louisiana. A notice of sixteen cases (reported 
from notes furnished by Dr. W. H. Geddings, of Charleston, S. C.) 
is also recorded by Dr. J. C. White.§ These were observed in 
Charleston, within a period of thirty years, upon the persons of 
four Jews, eight white Christians, three mulattoes, and one full 
negro. Cases have also been met with in Maryland, by Roh6|| 
and Atkinson,*! in New York, by Bulkley,** in Minnesota, 
among Norwegians, by Grunvold,tf and by Foye,|| among the 
Chinese, in California. The subject of leprosy in our country has 
lately received considerable attention, in the form of reports of 



* Leprosy in India. A report by T. E. Lewis, M.B., and D. D. Cunning- 
ham. M.B. Calcutta. 1877. 

f Xew York Med. Rec, 1881, vol. i. p. 212. 

I Annual Report of the Board of Health of the State of Louisiana for the 
Year 1880. New Orleans, 1881. 

\ Trans. Internat. Med. Cong., Phila., 1877. 

|| Maryland Med. Jour., July, 1878. 

If Trans. Amer. Derm. Assoc, 1881. 

** New York Med. Rec , 1881, vol. i. p. 212. Two cases are reported, who 
were born in this country, neither ever having been farther than five hundred 
miles from New York City : neither had any hereditary history or any personal 
relations whatsoever with the disease. 

If Trans. Amer. Derm. Assoc, 1878. 

XX Ibid., 1881. 



LEPEA. 497 

cases by Drs. Hyde,* Griinvold,f Bendeke,J Hoegh,§ Kohe,|| 
Salamon,f and Jones,** and in the collection of valuable infor- 
mation through the labors of the Committee on Statistics of the 
American Dermatological Association. ff It is certainly a fact that 
the disease exists sporadically in almost all sections of our country, 
in some localities more prevalently than in others, and in natives 
as well as in foreigners.!! The number is estimated variously at 
from fifty to one hundred. 

It will thus be seen that its distribution is very extensive. It 
is, of course, much more common in certain localities than in 
others, notably so in Southern Asia and in the islands of the 
Pacific Ocean. The disease seems to be caused by different in- 
fluences as it occurs in one country or in another; it therefore 
becomes difficult to determine upon the causes: certain points, 
however, are well settled. It is in many instances hereditary, 
and may be conveyed from parent to child through a series of 
generations. Concerning its contagiousness opinions differ. Drs. 
Lewis and Cunningham §§ do not consider it so. Dr. Enders,||H 
of the Sandwich Islands, on the other hand, believes that it is 
both contagious and inoculable. It is not unlikely, in my 
opinion, that it may be transmitted through the secretions and 



* Amer. Pract.j Feb. 1879 ; also Chicago Med. Jour, and Ex., Dec. 1879. 

f Trans. Amer. Derm. Assoc, 1879 ; also Arch, of Derm., Jan. 1879. 

% Trans. Amer. Derm. Assoc, 1879. 

\ Ibid. 

|| Maryland Medical Journal, July, 1878. 

I" Proceedings of the Louisiana State Medical Association, 1879. 

** New Orleans Med. and Surg. Jour., March, 1878. 

ff See Trans., New York, 1878-79. 

%% At Tracadie, in the province of New Brunswick, there has long existed 
a small colony of lepers. In 1863 they numbered twenty-three persons. 
They are French Eoman Catholics, and are said to be of the lowest class. 
The disease was probably introduced into the country by a French emigrant 
family from St. Malo, Normandy, in the early part of the present century. 
Leprosy also occurs on the island of Cape Breton, Nova Scotia. See notes of 
cases by Fletcher, reported by Macphedran, in Canadian Jour, of Med. Sci., 
Sept. 1881, and Jan. 1882. 

\\ Leprosy in India. Calcutta, 1877. 

Illl Louisville Medical News, 1879. See also an account of the disease as it 
exists in these islands, by this observer, in the Trans, of the Internat. Med. 
Cong, at Phila. Phila., 1877. 

32 



498 NEW GROWTHS. 

the blood, as in the case of syphilis. Piffard * entertains the 
same view. 

The most potent causes in the production of the disease appear 
to be intimately connected with climate, state of the soil, food, and 
habits of the people. Investigations concerning the nature of the 
climate in those countries in which the disease exists, point to no 
conclusions which throw any light upon the subject. From the 
geographical distribution, it will be seen that though more com- 
mon in tropical climates it occurs also in the coldest of climates, 
as, for example, Iceland and Norway. The state of the soil has 
been regarded by many as having a potent influence in the pro- 
duction of the disease, it being believed that a peculiar " malaria" 
is given off in the districts in which leprosy occurs. The majority 
of those attacked by the malady are in the lowest walks of life, 
surrounded by abject poverty and destitution, fit subjects for dis- 
ease of any kind. On the other hand, the disorder also attacks 
those in the most favored circumstances. The food used by the 
inhabitants in many of the leprosy districts is of an inferior qual- 
ity, consisting in great part of fish, oil, rice, and other articles of 
food peculiar to the country, and upon which the natives live 
almost exclusively. The disease occurs in both sexes, and may 
show itself at any period of life from childhood to old age. It 
has no connection with syphilis. 

Pathology. — The anatomy of leprosy has been studied by Dan- 
ielssen and Boeck,f Virchow,J Neumann, § Kaposi, || Carter,^ and 
others, with similar results. The disease consists in a deposit 
of new material, made up of cells similar to those encountered in 
lupus and in syphilis. The patches of infiltration and tubercles 
have been examined in all stages of development. Their struc- 
ture differs somewhat as they are recent or old formations. When 
cut into, well-formed tubercles present a firm, yellowish or red- 
dish, finely granular surface. The mass has its seat mainly in the 

* New York Med. Rec., 1881, vol. i. p. 212. 

f Traite de la Spedalskhed, avec un Atlas de 24 planches coloriees. Paris, 
1848. 

t Loc. cit., Bd. ii. p. 512. 

\ Loc. cit., p. 362. || Loc. cit., vol. iv. p. 172. 

\ Trans. Med. and Phys. Soc. of Bombay, 18G2, New Ser., vol. viii. ; 
Trans. Lond. Path. Soc, vols. xiii. and xiv. 



LEPEA. 499 

corium, but often extends down into the subcutaneous connective 
tissue. As a rule, it is not circumscribed, but inclines to spread 
out in the form of a diffused infiltration or as irregular processes. 
It consists of a delicate net-work, containing numerous, small, 
rounded, indifferent cells, closely packed together. According to 
Kaposi, in the younger tubercles the infiltration is not uniform, 
but consists of small foci, which are most numerous around the 
thick-walled bloodvessels, glands, and hair-follicles. The older 
the tubercles or patches of infiltration, the more numerous, uni- 
formly and densely crowded do the cells become, the intercellular 
substance finally almost completely disappearing. As the process 
advances, the epidermis, hair, sebaceous and sweat glands all 
atrophy, and in time become more or less obliterated. Ultimately 
the tubercles incline to soften, disintegrate, and break open into 
chronic, superficial or deep ulcers ; their course may be compared 
to that of the gummatous syphiloderm, although more sluggish. 

The nerves of the body undergo marked and peculiar changes. 
They have been fully described by Virchow* and others. The 
long nerves, as the ulnar or median, are, as a rule, chronically 
inflamed and swollen here and there along their course. The 
color is apt to be altered, being in place of the normal color gray- 
ish or of a smoky tint. The nerve is also generally firmer than 
normal. The neurilemma is usually more or less changed, and is 
at times hardened. The most important lesions, however, are 
observed in the septa within the nerve fasciculi, and in the inter- 
stitial substance, between the nerve fibres, and consist of a depo- 
sition of highly refractive, densely packed cells. These changes 
about the nerves account for the clinical symptoms of hyperes- 
thesia and anaesthesia which are so conspicuous in the disease. 

Diagnosis. — In countries where the disease is endemic, even the 
premonitory symptoms would be regarded with suspicion, while 
the appearance of the cutaneous eruption would leave no room 
for doubt; but not so in districts in which the disease occurs 
sporadically. The symptoms, however, taken as a whole, are of 
so marked a character that if they be borne in mind it will be 
almost impossible to err in the diagnosis. 

The macular and tubercular varieties are liable to be mistaken 

* Loc. cit., Bd. ii. pp. 522, 523. 



500 NEW GROWTHS. 

for syphilis.* The eruption, in its early stages, may resemble the 
macular or papular syphiloderm. It will be found to differ, how- 
ever, in the lesions being usually larger and more irregular both 
in size and in distribution. The erythematous patches of leprosy 
are often as large as the hand, and show signs of firm infiltration 
throughout the skin. The pigmentation is also peculiar, being of 
a dusky yellowish or brownish hue. The patches, moreover, have 
a smooth, glazed appearance. The tubercles assume various sizes 
and forms, but are for the most part larger than those of syphilis, 
being not infrequently the size of hazel-nuts or even of walnuts. 
They are apt to be irregularly shaped and unevenly raised above 
the surface, and are darker than those of syphilis. Their course, 
moreover, is usually slower than that of syphilitic lesions. The 
general expression of the face (the usual scat for this form of the 
disease) is peculiar, the tissues being all more or less infiltrated 
with the new growth, giving a swollen, ugly, leonine appearance 
to the features seldom seen in syphilis. 

Later in the course of the disease the tubercles and infiltrated 
patches break down, and become superficial or deep ulcers, covered 
with adherent blackish crusts, less bulky, as a rule, than those of 
syphilis. With ulceration come other characteristic symptoms 
of the disease, as anaesthesia, distortion of the hands and feet, 
absorption of bone tissue, atrophy, and other symptoms denoting 
profound constitutional infection. 

The yellowish, roundish patches of macular leprosy are not to 
be confounded with vitiligo. The diseases may be distinguished 
without difficulty by bearing in mind that in vitiligo the health 
is generally good, and that the patch of disease consists of simple 
absence of pigment with usually a border of an increased amount 
of coloring matter; the skin, moreover, is normal in texture and 
in sensibility, and smooth, the pigment change being the only sign 
of disease. The macules of leprosy, on the other hand, consist of 
infiltrated skin having the form of a distinct deposit of lardaceous- 
looking substance, which is generally firm and either markedly 

* A case of leprosy resembling syphilis, occurring in a Cuban gentleman, 
came under my observation in this city some years ago. The disease had been 
seen by a number of physicians, who viewed it as an ulcerating tubercular 
syphiloderm. For the report of this case, with photograph, see Phot. Rev. 
of Med. and Surg., vol. i. p. 72. 



LEPRA. 501 

hypersesthetic or anaesthetic. Macular leprosy is also to be dis- 
tinguished from morphoea, an affection of an entirely different 
nature. Morphoea is unattended by symptoms of constitutional 
disorder, the general health being usually good. The patches, 
moreover, differ from those of leprosy in being normal in sensi- 
bility, as well as in their course, which is one usually tending 
sooner or later to spontaneous recovery. 

Treatment. — This has proved extremely unsatisfactory. The 
many remedies which have from time to time been employed 
need not be enumerated : suffice it to say that they have proved 
powerless. As yet no specific has been found. The remedies 
usually now used, however, are of undoubted value in improving 
the general condition of the leper. The plan of treatment from 
which the greatest benefit has been derived is that which looks to 
the improvement of the general health. Change of climate and 
of residence is the first point to be attended to. A temperate and 
bracing climate should, if possible, be selected. The individual 
should at once seek a new home. Strict hygienic rules should be 
adopted, including proper exercise and frequent bathing. The 
subject of the nutrition of the body should also receive attention. 
The diet should be of the most nourishing kind. Tilbury Fox 
speaks well of quinine, and reports having obtained favorable 
results from its use in full doses. According to Brosse, Hoang 
Nan is a much more effective remedy for the fever than quinine. 
Iodide of potassium, iodine, arsenic, mercury, and cod-liver oil 
may also be administered, with a view to producing an alterative 
effect. Electricity is also of value. Symptoms are to be treated 
as they may arise. 

Several remedies, much employed in countries where the dis- 
ease is endemic, deserve special mention. They are Hydrocotyle 
Asiatica, Chaulmoogra oil (Oleum Ginocardise, from G. qdorata), 
Gurjun oil (wood-oil, from Dipterocarpus), and Hoang Nan (pow- 
dered bark of Strychnos Gautheriana). Chaulmoogra oil is best 
given in emulsion or in milk, in doses of five, ten, or more minims, 
beginning with a small dose and gradually increasing the quan- 
tity. Hillis* speaks favorably of it, and quotes Liveing, Cottle, 
and Young, all of whom derived benefit from its employment in 

* Leprosy in British Guiana, p. 218. London, 1881. 



502 NEW GROWTHS. 

a number of cases. Young,* of the Mission Hospital at Bombay, 
reports six illustrated cases, out of between fifty and sixty, treated 
by Chaulmoogra oil during eighteen months, five of which were 
markedly relieved. Piffard and Sturgisf also derived very de- 
cided benefit from its use in a case. Improvement, as a rule, 
occurs in less than two months. According to Dougal,| Espinet,§ 
and Hillis,|| Gurjun oil is even more valuable. Espinet concludes 
his report with the statement that " among the eleven patients 
submitted to the Gurjun oil treatment, only four followed it up 
regularly, but all four have improved both as regards their leprous 
symptoms and general health." According to the official report 
on the employment of Gurjun oil at the Leper Asylum, Mahaica, 
British Guiana,^ of thirty-two patients submitted to the treatment 
during nine months, "a very great improvement ill all the symp- 
toms occurm I in sixteen of the cases; eight had their symptoms 
ameliorated, and one case so far recovered that he was enabled to 
return to his family and friends. In all, twenty-five cases out of 
the thirty-two were much benefited." In a more recent report 
Hillis gives the history and treatment of a number of cases in 
which the remedy was used, concluding his remarks by repeating 
a statement made several years before, that in Gurjun oil we have 
"a most valuable medicine for the treatment of leprosy in all its 
forms; one capable of retarding the ravages of the disease, in 
some cases apparently curing it."** 

Another remedy without doubt of value is Hoang Nan, which 
is said to contain brucia and strychnia, and more of the former 
than of the latter. According to Brosse,|t it is besl given in three 
grain pills, one, two, or three being taken daily. Its use may 
be continued indefinitely. In appropriate doses it is a laxative; 
but in too strong doses the contrary effect is said to be produced. 
Brosse speaks in terms of high praise of the remedy. 

* Practitioner, Niov. 1878. 
f New York Med. Rec, July 10, 1880. 

I Report on the Treatment of Leprosy with Gurjun Oil. Calcutta, 1874. 
g Report on the Employment of Gurjun Oil in the Treatment of Leprosy 
at the Leper Asylum at Trinidad. 1876. 
|| Loc. cit. 

If By John D. Hillis, Brit. Med. Jour., April 26, 1879. 
** Loc. cit. 
ft New York Med. Rec, 1881, vol. i. p. 305. 



FRAMBCESIA. 503 

The local treatment is also important. Baths, medicated, as with 
iodine or sulphur, or simple, are of service. A number of remedies 
are used for the purpose of relieving the lesions of the skin, most 
of which are stimulating and tend to promote absorption of the 
infiltration.* Blistering, painting with iodine, and the mercurials, 
especially the acid nitrate, are of some value. The oil of cashew- 
nut, Gurjun oil, and Chaulmoogra oil, in the form of inunctions, 
are all highly recommended. The first of these has been used 
extensively by Beauperthuy.f Gurjun oil may be made into an 
emulsion with lime-water, one part to three ; and Chaulmoogra 
oil into an ointment, twenty or more grains to the ounce. 

Prognosis. — This is extremely unfavorable, for it is only in 
those cases in which the patient is able to devote every effort to 
the treatment of his disease that improvement is to be expected, 
and even in many of these cases the result is unsatisfactory. The 
sooner the disease is recognized and placed under treatment, the 
greater the hope of relief; after it has become disseminated through- 
out the tissues, the prognosis is dire. 

Frambcesia, called also yaws, pian, and endemic verrugas, 
is an endemic disease, characterized by general and cutaneous 
symptoms, occurring in the West Indies, particularly Jamaica and 
Dominica, in South America, in the Fiji Islands, in Ceylon, and 
along the east coast of Africa. It is occasionally encountered in 
our Southern States, especially Louisiana.! The affection has 
received study at the hands of Milroy § and Imray, of Dominica; 
Bowerbank,|] of Jamaica ; Hutchinson ;^[ and Ward, of Peru.** 
I shall describe the cutaneous symptoms only. The eruption 



* For a list of the remedies employed, as well as for a large amount of 
interesting material relating to the disease, see the Leprosy Eeport of the 
College of Physicians. London, 1867. 

f See Bakewell's report, Med. Times and Gaz., 1870, vol. i. p. 550. 

J See report of Prof. Jones to Louisiana State Board of Health, 1881, p. 
195 ; also New Orleans Med. and Surg. Jour., March, 1878. 

\ Report on Leprosy and Yaws in the West Indies, by Gavin Milroy, M.D. 
London, 1873. 

|| Quoted in Tilbury Fox's work on Diseases of the Skin. 

\ Catalogue of the New Syd. Soc. Atlas of Skin Diseases, Part II. p. 145. 
See also Plate XLI. 

** Trans, of the Internat. Med. Cong, of Phila. Phila., 1877. 



504 NEW GROWTHS. 

consists of variously sized reddish papules, tubercles, and tumors, 
which are usually present in all stages of development. They 
begin as pin-head sized, hard, red points, and later they reach the 
size of split peas, and resemble in appearance red currants or 
small raspberries. As they grow they incline to become flat on 
their summits and to be studded with yellowish points. In time 
they enlarge to the size of cherries, become softer in consistence, 
and are apt to break down and to ulcerate, discharging a thin, 
fetid, yellowish fluid. The lesions, although usually roundish and 
semiglobular, may be of any shape; at times they coalesce, form- 
ing patches of a vegetating or fungoid nature. The appearance 
of the eruption varies with the stage of the disease; also with the 
color of the patient, whether black or white. According to Dr. 
Imray, "if yaws are observed as they first make their appearance 
on the surface, one or more minute whitish or yellowish points or 
spots will be perceived, not larger than a pin's head. These yel- 
low spots are seeu very distinctly on the dark skin of the negro. 
Gradually the .-put- enlarge, and begin t<» project from the surface, 
retaining for the most pari their circular form, and have much 
the appearance of small globules of yellow pus." The Bame 
writer compares the typical tubercles to a •• piece of coarse cotton 
wick, a quarter of an inch, more or less, in diameter, dipped into 
a dirty yellow fluid, and stuck on the skin in a dirty, scabby, 
brownish setting, and projecting to a greater or less extent," which, 
although not so elegant a comparison as that of the strawberry, he 
believe- to be more exact. Mr. Hutchinson, who reports a case 
occurring in an Englishman, compares the appearance of the 
lesions to red currants, with flat tops, of a bright-pink color, 
glassy, and semi-transparent, but possessing the consistence of a 
raspberry rather than that of a currant. Larger formations, he 
adds, look not unlike small cherries. The surface of the tubercles 
varies; it may be smooth or .-lightly scaly, or in a state of ulcer- 
ation, covered with thin yellowish fluid and crus 

The eruption generally manifests itself on the face, on the upper 
and lower extremities, and about the genitalia, the largest growths 
occurring on the lips, eyelids, toes, and genital organs. The lesions 
show no regularity of distribution. They are, as a rule, neither 
painful nor itchy. The course of the disease is variable; it may 
continue for months, or, if neglected, for years. The disease is 



PELLAGRA. 505 

considered by most observers to be contagious.* It is probably 
not hereditary. It has no relation to syphilis. The treatment, 
according to Dr. Imray, "is as simple as it is usually effective," a 
view likewise entertained by Dr. Milroy and others. It consists 
in attention to cleanliness, hygiene, good food, and judicious use 
of tonics. Locally, the lesions are best treated with a carbolic acid 
solution or with a weak nitrate of mercury ointment. 

Pellagra, known also as risipola lombarda, mal rosso, 
mal de la rosa, and lombardian leprosy, is an endemic, 
constitutional disease, characterized by a chronic inflammation of 
the skin, of an erythematous nature, accompanied usually with 
derangement of the digestive tract and cerebro-spinal symptoms. 
The eruption is confined to those parts which are commonly 
exposed to the sun, as the backs of the hands and feet, arms, 
legs, chest, and neck. The skin becomes reddish, and is the seat 
of violent burning sensations, which are greatly aggravated by 
exposure to the sun. The inflammation may be superficial or 
deep-seated. Later the epidermis begins to desquamate, leaving a 
reddish, shining, often fissured surface. According to Kayer,f the 
inflammation may be intense, the epidermis rising into vesicles 
or large, irregularly-shaped bulla?, succeeded by crusts. In other 
cases the epidermis becomes thickened, hard and dry, yellowish or 
brownish in color, without having been preceded by redness or 
burning. The symptoms are at their height during the summer, 
subsiding with the advent of winter, and returning the following 
year, usually in an aggravated form. Marked disturbance of the 
health may occur with the cutaneous manifestations, consisting of 
loss of appetite, thirst, nausea, indigestion, pains in the abdomen, 
with diarrhoea or constipation. The patient becomes debilitated 
and feverish, and loses weight. In addition, nervous symptoms, 
characterized by vertigo, pains in the head and spinal cord, delirium, 
convulsions, loss of memory, loss of muscular power, and mel- 
ancholia, often follow. The course of the disease is variable; it 

* On this question a paper of Dr. Nicholls may be consulted, Med. Times 
and Gaz., vol. i., 1880. Several other articles giving much valuable informa- 
tion concerning the disease, by Drs. Bowerbank and Milroy, may be found in 
the same volume. 

f Treatise on Diseases of the Skin. Eng. trans., London, 1835. 



506 NEW GROWTHS. 

may continue several years or indefinitely. It is usually amenable 
to treatment, but among the poorer classes frequently proves fatal. 
It is endemic in the northern districts of Italy, especially Lom- 
bardy and Tuscany ; it is also met with in Southern France and in 
Spain. It is said to occur also sporadically in other countries, as 
in Roumania. It occurs chiefly among the poorer population, 
notably those pursuing agricultural occupations. It attacks both 
sexes, but is commoner among women, and manifests itself chiefly 
in middle age; but it is said to occur at all ages, and even in chil- 
dren and infants. The cause of the disease has long been the 
subject of discussion, although it is now generally conceded that 
it is produced by the use of diseased (ergoted) maize, which the 
inhabitants of the pellagrous districts consume in large quantities 
as an article of food. According to Haberlandt,* it is due to the 
rancid oil of the maize. It has also been attributed to malaria, bad 
hygiene, extreme poverty, bad water, and like causes, all of which 
are usually found to exist where the disease is endemic. The sun 
is the exciting cause. The treatment is directed against the gen- 
eral condition. 

SYPHILODERMA. 

Syn., Syphilis Cutanea; Dermatosyphilis ; Syphilis of the Skin. 

Under this term are included the various manifestations of 
syphilis upon the skin. The syphilodermata, or syphilides, as 
they are also termed, are numerous and constitute an important 
group of symptoms. They occur in a variety of forms, present- 
ing themselves, in fact, in the different lesions common to other 
cutaneous affections. They may occur at any period in the course 
of the disease, giving rise cither to but slight inconvenience, or, on 
the other hand, to serious disfigurement or deformity. Before 
describing them in detail, there are certain general features, char- 
acteristic of the group, which require consideration. Although 
these vary as to the degree in which they are expressed, they are 
nevertheless of significance and of value in a diagnostic point of 
view. They may be referred to under the following heads. 

General Symptoms. — These, as a rule, are absent. With the 
exception of the syphilitic fever, which ushers in the secondary 

* Quoted by Neumann, loc. cit. 



SYPHILODERMA. 507 

stage of the disease, and especially the erythematous syphilo- 
derm, there are rarely any signs indicative of systemic disturbance. 
Slight fever, loss of appetite, weakness, rheumatoid pains of the 
muscles, aching of the bones, especially of the ulna and tibia, and 
headache, usually confined to one lateral half of the head, are 
occasionally noted to precede certain of the diffused eruptions ; 
but more often they are not experienced, the eruption manifest- 
ing itself without constitutional symptoms. The patient in the 
majority of cases enjoys average general health. 

Concomitant Symptoms. — Other signs of syphilis are ordi- 
narily present. In the early eruptions, the chancre or its scar, 
induration of the inguinal glands, engorgement of the cervical 
glands, sore throat, alopecia, and mucous patches about the mouth 
and genitalia, may be looked for; one or more of these symptoms 
will usually exist during the first three or four months. With 
the later eruptions, those occurring after the first year, osteocopic 
pains, bone lesions, permanent alopecia, and other symptoms point- 
ing directly to syphilis, will often be present. 

Seat. — They confine themselves to no particular region. All 
parts of the integument are liable to their invasion. The different 
forms of eruption, however, have decided preference for certain 
localities. The earlier eruptions are generalized more or less over 
the entire body, while the later lesions are less numerous and are 
widely distributed. The erythematous syphiloderm is observed to 
show itself most markedly upon the trunk; papules are prone to 
develop about the genitalia, and at the back of the neck ; tubercles 
are frequently encountered upon the face and back; while the 
palm 5 and soles are the usual seats for the papulo-squamous mani- 
festation. Symmetry is, as a rule, noted in the earlier, diffused 
eruptions only; later, the distribution of the lesions is generally 
irregular. 

Multiformity of the Lesions. — They assume a great variety 
of forms of primary eruption, manifesting themselves as macules, 
papules, pustules, tubercles, and blebs, together with numerous 
modifications. Of these the papule is the most common. They 
have a marked tendency to appear associated together. They 
either succeed one another, or, as is more usually the case, several 
make their appearance at the same time. Thus, macules and 
papules are frequently simultaneously present ; likewise papules 



508 SEW GROWTHS. 

and pustules. At times, especially in the early eruptions, a num- 
ber of different lesions, including macules, maculo-papules, pustules, 
vesico-pustules, scales, crusts, and fissures, are disseminated over 
the surface. Polymorphism is more apt to be observed in the 
earlier than in the later lesions, although it may occur in these 
also. The lesions undergo evolution without fixed laws, a papule, 
for example, either remaining such, undergoing modification, or 
becoming a pustule. Thus, they observe no regularity of course. 

Configuration of the Lesions.— The earlier lesions tend to 
assume a rounded form, but later they possess a marked disposi- 
tion to appear in a circular, semicircular, crescentic, or serpiginous 
arrangement. This is particularly the case in regard to the later 
manifestations, as, for instance, recurrent papules, and tubercles. 
The latest lesions, however, when single, often preserve in a 
marked degree the rounded form. 

Color. — The color varies according to the lesions, the stage 
of development, and also the subject, whether of light or dark 
complexion. The earlier lesions are at first of a pinkish red, but 
of a more subdued, duller tint than that of the other exanthemata. 
As the freshness fades, the lesions gradually assume the so-called 
syphilitic hue. Sometimes they possess it from the beginning. 
The syphilitic tint — which, however, caunot be regarded as char- 
acteristic, being shared by other diseases, as, for example, lupus 
vulgaris and psoriasis — is most pronounced in papules and tuber- 
cles. It may be described as being either of a pale or dull brown- 
ish red or a dull yellowish red, or copper color. The brownish- 
red hue, likened also to the color of a slice of lean ham, usually 
finds its expression in papules, while the coppery tint is more apt 
to be observed in tubercles. 

Course. — No laws as to time govern the evolution of the 
lesions of syphilis; but their course is usually slow. They may 
not uncommonly be observed to pass from one to another, as, for 
example, papules into pustules. They possess a marked inclina- 
tion to recur from time to time. They are cold or non-inflamma- 
tory in character, and in this respect differ from the inflammatory 
diseases, some of which they so frequently resemble in appearance. 

Subjective Symptoms. — It is only rarely that they are ac- 
companied by itching or burning sensations. As a rule, no 
subjective symptoms are present. Not infrequently, indeed, the 



SYPHILODERMA. 509 

patient is first made aware of their presence by seeing or feeling 
them. If, however, they be subjected to external irritation, as 
friction, sweat, or other irritants, itching may occur. The small 
papular and pustular syphiloderm at times proves an exception to 
the rule, being not infrequently accompanied by itching. On the 
scalp the disease is also occasionally the seat of itching. The lesions 
are rarely accompanied with pain. Ulcers, however, if connected 
with bones, or when upon the extremities, especially the legs, often 
pain considerably, and sometimes excessively. 

Syphiloderma Erythematosum. — {Syn., Erythematous 
Syphiloderm ; Macular Syphiloderm ; Erythematous Syphilid e ; 
Syphilis Cutanea Maculosa; Roseola Syphilitica; Exanthematous 
Syphilide.) 

This consists in the formation of macules of various sizes and 
shapes, appearing as a general eruption. The lesions are upon a 
level with the surrounding skin, or are very slightly raised, and 
disappear under pressure. In size they vary from a split pea to 
a finger-nail. In shape they are somewhat irregular ; they may 
be roundish, ovalish, or, rarely, circinate. Their outline is for the 
most part ill defined; but change of temperature, especially to 
cold, is apt to cause them to stand out more prominently. Some 
are always better defined than others. As usually seen, they give 
to the skin a mottled or marbled look. They are of a pale or dull 
pinkish or reddish color, which, however, varies considerably with 
their age, and also with the natural complexion of the individual. 
At first they are of a delicate rosy hue, and may be readily effaced 
by pressure ; later they become somewhat darker, usually passing 
into a dusky-pink or purplish tint, which is for the time perma- 
nent. As they fade away they take on a pale, dirty-yellowish, 
grayish-brown or coppery shade. In number they are always 
multiple; they may exist sparsely, or, as is usually the case, in 
profusion, and at times to such an extent as completely to cover 
the whole surface. Where they are present in large numbers they 
may run into one another. 

As a rule, they first show themselves in the neighborhood of the 
umbilicus, soon extend to the thorax, and later upon all parts of 
the body, but they are always particularly well marked about the 
trunk and flexor surfaces of the limbs. The palms and soles often 



510 NEW GROWTHS. 

exhibit them ; the backs of the hands and feet, however, only 
rarely. The face frequently escapes. They evince no disposition 
to form into patches, circles, or other arrangement; they appear 
without order of distribution.* The eruption is unaccompanied 
by symptoms of heat or itching, except when it comes out sud- 
denly over large tracts; frequently the patient is unaware of its 
presence until it has existed for some days. 

The erythematous syphiloderm is the earliest of the syphilo- 
dermata. It generally makes its appearance from the sixth to the 
eighth week from the date at which the initial lesion, or chancre, 
was first noticed ; at times, however, it shows itself at a much later 
period, occasionally as late as the second year, when it may assume 
the circinate form. Its appearance is retarded by treatment. It 
may show itself with or without systemic disturbance; often it 
is ushered in with malaise and slight fever of short duration, 
the so-called syphilitic fever. It is usually accompanied by other 
signs of syphilis, as the chancre itself or its scar, engorged cervical 
ganglia, erythema or mucous patches of the fauces, pains about 
the body, especially the joints, alopecia, and superficial scaling of 
the palms and occasionally of the soles. 

The development of the eruption is usually slow, several days 
or a week elapsing before it reaches its height, though individual 
patches reach their full size in a few days; at times, however, it 
breaks forth with rapidity and violence. Its appearance may be 
hastened by undue excitement or over-exertion; sometimes it is 
brought out by a hot bath. Its duration is variable, depending 
on the degree of hyperemia and upon treatment; it may last a 
few weeks, a month, or longer. It fades away gradually, un- 
attended, as a rule, by desquamation, leaving a slight grayish, 
brownish-yellow, or yellowish pigmentation of the skin, which 
in turn likewise slowly disappears. Relapses may occur during 
the first year, the eruption being generally less copious. It is 
encountered more frequently than any other form of syphilitic 
eruption. It is very common, probably occurring in almost all 
cases of syphilis, although frequently escaping observation. It 
varies, however, exceedingly in the degree of its development; at 



* A representation of the usual form of the efflorescence may he found in 
Plate J of my Atlas of Skin Diseases. 



SYPHILODEEMA. 511 

times it is pronounced, while in other cases, as stated, it is so slight 
as to escape detection. Treatment, as a rule, causes it to vanish 
rapidly. 

The diagnosis is ordinarily not difficult. It is to be distin- 
guished from measles, rotheln, and urticaria; from the eruptions 
due to certain drugs, especially belladonna, bromine, copaiba, 
cubebs, iodine, mercury, and quinine ; and from tinea versicolor, 
and the simple erythemata. The absence of febrile and catarrhal 
symptoms, and its course, will serve to prevent its being con- 
founded with measles. The eruption of measles, moreover, is 
peculiar, being crescentic in form, and blotchy. Rotheln, or 
German measles, is characterized by small, roundish, often con- 
fluent, pinkish or reddish patches; is, moreover, preceded by 
pyrexic symptoms, and is accompanied by slight inflammation of 
the mucous membranes, as in measles. The eruption fades on 
the fourth or fifth day. It is an epidemic disease, and usually 
occurs in young children. Urticaria may always be known by 
its sudden appearance, the presence of wheals, the short duration 
of the eruption, and the constant and marked feature of itching. 
The efflorescence following the ingestion of copaiba or cubebs 
consists of isolated or confluent urticarial patches, reddish in color, 
of short duration, and dependent upon the use of these drugs ; 
decided itching, moreover, is usually present. The grouping and 
localization of the other medicinal eruptions, the fever usually 
attending their appearance, which is commonly sudden in its ad- 
vent, and the history, will usually serve to render the diagnosis 
easy. The macules of tinea versicolor become at times pinkish, 
reddish, or brownish yellow in color, and, where they happen to 
be small, numerous, and disseminated, may resemble the syphilo- 
derm; but upon close inspection they can scarcely be confounded. 

Syphiloderma Papulosum. — (Syn. } Papular Syphiloderm ; 
Papular Syphilide; Syphilis Cutanea Papulosa.) 

This is characterized by the formation of papules, which vary 
greatly as to size, shape, distribution, and course. The appear- 
ances presented are altogether different as the lesions happen to be 
small or large, acuminated or flat, disseminated or grouped. The 
various stages through which they pass, moreover, and the modi- 
fications to which they are subject, give rise to symptoms which 
render a separate description of them necessary. 



512 



NEW GROWTHS. 



Small Papular Sijpluloderm.—(Syn., Miliary Papular Syphi- 
loderm ; Lichen Syphiliticus.) This form consists of an erup- 
tion of disseminated or grouped, more or less confluent, small 
or minute papules. They are pin-head or millet-seed sized ; are 
distinctly elevated ; and have a firm or solid, somewhat harsh or 
rough, feel. In shape they are rounded and acuminated. Their 
summits may be perfectly smooth or covered with fine scales; not 
infrequently slight pointed pustulation may be noticed, especially 
in those through which a hair protrudes; while small, well-defined 
miliary pustules, in varying numbers, may complicate the erup- 
tion, such a combination of lesions being by no means uncom- 
mon.* The lesions are sometimes bright in color, and when in 
profusion, occurring as an early general eruption, may be of a vivid 
hue; but later they become darker or of a brownish red. The 
eruptioo is apt to be well marked, and usually occupies a large 
amount of surface, either in a disseminated manner or in groups, 
thickly studded, constituting at times almost solid patches. It is 
often seen about the shoulders, arms, trunk, and thighs. 

It may be either an early or a late manifestation ; occasionally 
it appears during the third or fourth month, in other cases not 
until later, after other lesions have occurred. It has a chronic 
course, and is often rebellious to treatment. It is, I think, more 
commonly met with in men than in women. Relapses are com- 
mon. Large flat papules, as well as moist papules, may often be 
found existing at the same time upon other regions of the bo<lv. 

It may be mistaken for keratosis pilaris in those cases where the 
papules are minute, pierced by a hair, and disseminated in great 
numbers over the body and extremities especially in the colored 
race. It also bears a close resemblance to lichen scrofulosus and 
to psoriasis punctata. It is not to be confounded with papular 
eczema. It may usually be diagnosed by the presence of other 
symptoms of syphilis. 

Large Papular St/philoderm.—(Syn., Lenticular Papular Syphi- 
loderm.) The lesions here are large flat papules, different in size, 
shape, and general characteristics from the miliary lesions. In size 
they vary from a small split pea to a large finger-nail. In shape 



* A representation of both lesions occurs in the case portrayed in Plate L 
of mv Atlas of Skin Diseases. 



SYPHILODEEMA. 513 

they are generally circular or ovalish. They are firmly seated in 
the skin, are more or less raised above the surrounding tissue, and 
have a flat surface. To the touch they are firm and circumscribed. 
In their early stage they are usually smooth and free of exfoliating 
epidermis. Their color is a pale or deep dull-red, variable as to 
shade, but generally showing the raw-ham tint; at times they are 
so dark as to have a brownish or violaceous color. They are usually 
present in numbers, although seldom to the extent of the small 
papules. They may show themselves upon all parts of the body, 
either as a disseminated or as a localized eruption. They also 
tend at times to group, and to form patches. The forehead, region 
of the mouth, nape of the neck, back,* flexor surfaces of the ex- 
tremities, scrotum, labia, perineum, and margin of the anus, are 
all favorite localities for their development. 

The eruption is one of the commonest of the syphilodermata. 
It may be the earliest manifestation, or it may first occur later. 
It may also appear in later years as. a relapse. It is generally en- 
countered closely following the erythematous form, and may even 
appear simultaneously. The lesions, as a rule, develop themselves 
slowly, in the course of a few weeks, and attain to various sizes ; 
they are usually present in all stages of growth. Once formed, 
they are apt to remain for weeks or months. They are more 
amenable to treatment than the miliary papules. They are to 
be diagnosed from the lesions of acne and lichen ruber planus. 
Other symptoms of syphilis will almost invariably be present. 

Large flat papules undergo more or less modification according 
to the locality in which they exist, while other influences also cause 
them to become altered in general appearance and in form. These 
changes are of so marked a character as to call for special descrip- 
tion. They are not infrequently so complete as to mask the original 
lesion. Their recognition may thus become a matter of difficulty. 
As they progress in their course they may either continue as typical 
lesions, and as such sooner or later pass away by absorption, or 
they may metamorphose in the following manner. At times they 
become soft and spongy, and incline to disintegrate. When this 
occurs, they lose their form, and usually sink to the level of the 

* See Plate A A in my Atlas of Skin Diseases. 



514 XEW GEOWTHS. 

surrounding skin. From one cause or another they may also show 
signs of excoriation, when slight crusting takes place; but marked 
ulceration seldom occurs. Fissures not infrequently exist, and are 
sometimes deep and painful. They are usually observed about the 
angles of the mouth, the anus, and other parts exposed to motion. 
The commonest change of the papule, however, is into the 

Moist Papule.— (Syn., Mucous Papule; Mucous Patch; Broad, 
or Flat, Condyloma; Plaque Muqueuse.) 

This takes place upon those regions where opposing surfaces 
and natural folds of skin are subject to more or less contact, as, 
for example, the nates, perineum, genitalia, groins, axilla?, um- 
bilicus, and beneath the mammae in women. Parts influenced by 
excessive glandular secretion, either of sebum or sweat, as about the 
spaces between the fingers and toes, are also liable to be invaded. 
The lesions differ from the large, dry papules in that they are more 
or less moist, and are covered with a grayish, mucoid secretion, 
consisting of macerated epidermis. They are also Hatter than dry 
papules, and are often without defined outline. They vary in con- 
sistence, but are generally soft or spongy. Not infrequently they 
coalesce, producing patches of considerable size; about the genitalia 
large surfaces are often so involved. 

Instead of becoming flat, they may take on action which re- 
sults in the formation of luxuriant, hypertrophic, warty, papillary 
growths, when they are designated "hypertrophic" or "vege- 
tating" papules. This manifestation constitutes the VEGETATING 
SYPHILODERM, known also as SYPHILIS CUTANEA VEGETANS. 
The lesions assume an elevated, more or less circumscribed, 
warty character, resembling the raspberry or cauliflower forma- 
tion. Betweeu the papillary growths there may be slight ulcera- 
tion, accompanied with offensive secretion, which drying forma 
yellowish or brownish crusts. They are most prone to occur on 
the face, on the scalp, about the shoulders, and near the genitals, 
and are not to be confounded with acuminated or venereal Mart. 
(See Verruca acuminata.) Their secretion is contagious, although 
not auto-inoculable ; they are, however, observed to multiply abun- 
dantly in those regions favorable for their development simply 
by the presence of the irritating secretion. They are notable for 
the rapidity with which they develop and increase in size. They 
constitute a luxuriant growth. Heat, moisture, friction, unclean- 



SYPHILODERM A. 515 

liness, all contribute to their development. They are amenable 
to treatment. Local measures usually act promptly in causing 
them to disappear. 

To return to the dry papules. Frequently after having fully 
developed, or even in their early stage, another and different 
process may be established, namely, that of desquamation. When 
this takes place, they become " squamous papules." The modifica- 
tion is a very common one, and constitutes the 

Papulo-Squamous Syphiloderm. — {Syn. y Squamous Syphilo- 
derm; Syphilis Cutanea Squamosa ; Psoriasis Syphilitica.) 

It presents different appearances as it occurs in one locality or 
another, and according to the arrangement of the lesions. They 
may be isolated, grouped, or closely packed together forming 
patches. They are generally flattened, and are covered with a dry, 
grayish, adherent scale. This may be thin and scanty or relatively 
abundant, although seldom so luxuriant as in psoriasis. If the 
scales be removed, elevated or flattened, diffused or circumscribed 
papules, pale or dull red in color, are usually detected. The 
eruption is rarely extensive ; may show itself upon any portion 
of the body, with preference, however, for the palms and soles ; 
and is remarkably persistent in its course. 

Owing to the peculiarity in the structure of the skin of the 
palms and soles, the disease assumes an appearance here altogether 
different from that seen elsewhere. It is known as the palmar 
and plantar syphiloderm, and is entitled to special descrip- 
tion. The lesions often partake of the nature of macules rather 
than of papules, yet the characteristics are such as to permit of no 
doubt of their being modified papules. They are slightly raised 
above the level of the surrounding skin, and, as a rule, are ill 
defined. In size they vary from a split pea to a finger-nail. In 
shape they are irregular, and, on account of their tendency to 
coalesce, are seen in the form of roundish, serpiginous, or cres- 
centic patches. They are covered with dry, scanty, semi-detached, 
grayish flakes of epidermis. These are adherent, and are most 
abundant about the edge of the patch, Avhere they are ragged or 
have a wrinkled or dried-up appearance. If they be removed, the 
surface beneath will usually be of a dull-red, raw-ham color. At 
times the exfoliation takes place abundantly and presents a dis- 



516 NEW GROWTHS. 

tinctly squamous patch ; it may either be cast off or may remain 
upon the surface, in which event it may give a hard, horny coat- 
ing to the part. Sometimes the upper layers of the epidermis 
covering the sole, and less frequently the palm, become the seat of 
small punctate epithelial concretions, from which corneous masses 
may be dug out; or they are perforated with minute holes, with 
clear-cut, punched-out edges. The condition constitutes the syphi- 
lide cornee of French writers. In other cases little or no 
desquamation occurs, the patch presenting more of an erythema- 
tous look. The patches may be either hard or soft to the feel, 
according to the form in which the lesion shows itself; the more 
circumscribed the papule or deposit, the greater will be its firm- 
ness. In addition to the lesions described, fissures usually exist, 
extending at times deep into the corium. 

The eruption is usually symmetrical, and is apt to appear in the 
centre of the palm or sole, upon the ball of the thumb, and about 
the volar surfaces of the fingers. It rarely attacks the hacks of the 
hands or feet; nor docs it usually spread extensively, as, for, ex- 
ample, over the wrist. Occasionally, however, when a large patch 
has formed in the hollow of the hand or upon the sole, the disease 
extends itself by a distinctly elevated erescentic border. As it in- 
vade- healthy tissues the parts formerly attacked remain subacutely 
inflamed and more or less scaly. The whole palm or sole, together 
with the skin between the fingers and toe-, may be thus involved. 
Sometimes the lesions progress in this manner up the inner side of 
the loot towards the ankle, and also around the radial and ulnar 
borders of the hand, generally, as stated, avoiding the dorsum, 
and seldom passing beyond the wrist. The eruption may be 
limited to a small patch the size of a coin, or it may involve the 
greater part of the surface. As a rule, neither heat nor itching 
is present Its course is exceedingly chronic, frequently lasting 
months and years. It may appear either as a comparatively early 
or as a late manifestation. If it occur upon only one hand or foot, 
it is apt to be a late eruption, often years after the initial lesion. 

The papulo -squamous syphiloderm is liable to be confounded 
with eczema and psoriasis, and also with callosity. From eczema 
it may be distinguished by the absence of heat, itching, and dis- 
charge, the two former of which symptoms are almost always 
present in eczema. The course of the eruption, and its history, 



SYPHILODERMA. 517 

will also be of assistance in the diagnosis. It often resembles 
psoriasis very closely, whether occurring upon the trunk, extrem- 
ities, or palms and soles. The differential diagnosis may be stated 
as follows : the syphiloderm is almost invariably confined to adult 
age, being the result of acquired syphilis; psoriasis frequently 
manifests itself in early life, usually before the age of twenty. In 
connection with the syphiloderm there is generally some clue to 
the initial lesion of syphilis ; on the other hand, in psoriasis the 
characteristic history of psoriasis is ordinarily obtainable. 

The patches of the syphiloderm show no tendency to adopt a 
system of configuration ; they may take upon themselves any pat- 
tern as to form, usually varying their shape according to locality. 
Frequently, however, the lesions composing the patch assume a 
circular or semicircular arrangement, usually more noticeable 
where the eruption is limited in extent. Psoriasis, on the other 
hand, generally inclines to assume some definite pattern. The 
edges of the patches of the syphiloderm are generally elevated, 
and possess a marked line of demarcation, the disease terminating 
abruptly against the healthy skin. This margin may often be 
detected by passing the finger over the surface, and is the line of 
the syphilitic deposit. Upon the palm or sole it is generally less 
defined than on other parts of the body. The edges here, as a 
rule, are only slightly raised, but are apt to be covered with thin, 
filmy, shrivelled scales. In psoriasis, the elevation of the patch 
and its border are due to the scales ; if these be thoroughly re- 
moved, a red, shining surface, not much, if at all, raised above 
the level of the skin, is observed. 

The syphiloderm, except when it attacks the palms and soles, 
and even here it is subject to variation, has no tendency to occur 
symmetrically. Psoriasis, on the other hand, generally manifests 
a disposition to symmetry. The syphiloderm ordinarily confines 
itself to one portion of the body, the amount of surface involved 
being usually small in extent; sometimes, however, it is extensive. 
It rarely occurs upon the elbows or knees. Psoriasis attacks re- 
mote parts of the body simultaneously, and has a strong predi- 
lection for the elbows and knees. 

Both the syphiloderm and psoriasis may invade the palms 
and soles ; both diseases may also appear exclusively upon either 
the palms or soles, the rest of the body remaining entirely free. 



518 NEW GKOWTHS. 

"When psoriasis, however, exists upon the palms or soles, it is 
common to see it at the same time on other regions. When the 
syphiloderm, on the other hand, attacks the palms or soles, it is 
the rule to find no trace of it elsewhere. Slight itching may be 
present with the syphiloderm, particularly if seated on the trunk, 
but rarely to such an extent as to cause the patient to scratch. 
Psoriasis is apt to be attended with more or less itching; at times 
it is even severe. The syphiloderm is usually slow in its course j 
psoriasis is generally a more active process, sometimes extending 
itself rapidly. 

The syphiloderm manifests itself in the form of a deposit in 
the skin; in psoriasis there is no deposit, but simply a hyperplasia 
of the cells of the rete, producing hyperaemic or inflammatory 
symptoms. This difference in the pathological structure of the 
patches is generally appreciable even to the naked eye, and con- 
stitutes one of the most valuable diagnostic signs between the 
diseases. Exclusive of the seal-, there is but little thickening 
of tissue in the ordinary patch of psoriasis; in syphilis there is 
decided infiltration throughout the skin. But care must some- 
times be exercised in discriminating between the thickening due 
to inflammatory swelling and that arising from syphilis. 

The syphiloderm usually consists of more than one kind of 
lesion, a variety indeed being at times observable, composed of 
papules, fissures, ulcers, and scales; in psoriasis all the lesions 
show the same pathological characters, the patch being made up 
of a circumscribed more or less inflammatory surface covered with 
sea'-. The color of the syphiloderm is usually less vivid than 
that of psoriasis, and often has a dull, smoky, brownish-red tint. 

The scales of the syphiloderm have a grayish or yellowish, often 
dingy, dried or shrivelled look; in psoriasis they are generally 
whitish, and have the appearance of being recently formed. In 
syphilis they are produced slowly, and exist scantily; in psoriasis 
they are formed rapidly, and are usually present in quantity. In 
syphilis, moreover, the scales are adherent; in psoriasis they are 
non-adherent or loose, and are easily detached from their bed. 
The syphiloderm may usually be denuded of its scales without 
provoking blood; the psoriatic patch will bleed much more easily 
under the same circumstances. These points of difference are all 
valuable for diagnosis. In syphilis the papules may break down 



SYPHILODERMA. 519 

and show signs of moisture or even superficial ulceration ; in pso- 
riasis the process is a dry one throughout its course. Finally, in 
doubtful cases, treatment will aid in the diagnosis. The syphilo- 
derm, though persistent and stubborn in its course, when once 
entirely removed by treatment is not apt to return ; the tendency 
of psoriasis is to recur at intervals through life. 

Syphiloderma Yesiculosum. — (Syn., Vesicular Syphilo- 
derm ; Vesicular Syphilide ; Syphilis Cutanea Vesiculosa.) This 
is a rare manifestation. Vesicles are very seldom encountered in 
syphilis. In the majority of instances, so-called syphilitic vesi- 
cles may be more properly viewed as early pustules; occasion- 
ally, however, the lesions are of such character throughout their 
course as to be entitled to the term vesicular. The few exam- 
ples that I have seen occurred in hospital practice, and in women. 
The eruption has been described at length by Bassereau* and 
Hardy.f 

The lesions vary in size, form, arrangement, and distribution. 
They may be small, pin-head sized, more or less acuminated, and 
disseminated or grouped, or split-pea sized, flat or semiglobular, 
with or without umbilication. The small, miliary vesicles mani- 
fest themselves as irregularly grouped or disseminated lesions, 
inclining to involve the hair-follicles, and are succeeded by minute, 
yellowish, granular crusts. They frequently pass into miliary 
pustules. The larger vesicles are apt to occur as a disseminated 
eruption, and show a disposition to assume the form of the vesicle 
of varicella, whence the term varicella-form syphiloderm. 
The lesions here are usually split-pea sized, slightly umbilicated, 
contain a clear or cloudy fluid, are surrounded with a more or less 
marked pale-reddish areola, and, considering their vesicular char- 
acter, are remarkable for their persistency, at times remaining days 
without undergoing appreciable change. They may be discrete or 
confluent. At times they group in an ill-defined crescentic manner. 
They are succeeded by small light-yellowish or grayish-yellow 
crusts. 

The eruption shows itself in localities where the skin is natu- 

* Traite des Affections de la Peau symptomatiques de la Syphilis. Paris, 
1852. 

f Lecons sur la Scrofule et les Scrofulides et sur la Syphilis et les Syphilides. 
Paris, 1864. 



520 



XEW GROWTHS. 



rally thin, as on the face and about the genitalia. It is rarely 
extensive in its distribution, nor are the lesions apt to be numerous. 
Its course is usually rapid. The lesions terminate either in ab- 
sorption or in rupture and slight crusting. It seldom exists alone, 
papules, either large flat, or small, being also usually present over 
other regions of the body. Other signs of syphilis are generally 
present. As originally pointed out by Bassereau, it is an early 
eruption, occurring during the first year, and usually within the 
first six months. 

Syphiloderma Pigmentosum.— This affection, the pigmen- 
tary syphilids of the French, has been described by Hardy* 
and Fournier,f two accurate observers, and more recently in our 
country by G. H. Fox J and I. E. Atkinson.§ It consists of a 
more or less circumscribed pigmentation of the skin, in the form 
of roundish, ovalish, or irregularly shaped, split-pea or finger-nail 
sized, discrete or confluent macules. They are on a level with the 
surrounding skin, and have a smooth surface; they are, in fact, 
simple pigmentary deposits. They are not preceded by hyperemia, 
nor do they follow upon the sit., of other syphilitic lesions, a view 
which is likewise shared by Atkinson. They have a pale-grayish 
or brownish-yellow, coffee-with-milk color, and are sometimes sur- 
rounded by skin which is whitish or paler than normal, causing 
them to stand out more conspicuously. No! infrequently the color 
is so faint that the lesions may for a time escape detection. They 
often have the appearance of being dirt- marks rather than disease. 
They are generally faint and ill defined, and are apt to coalesce, 
forming a delicate net-work, or a more or less broken, marbled' 
patch of discoloration. 

The affection is unaccompanied by subjective symptoms. It is 
most frequently encountered on the neck, upon one or both sides; 
according to Fournier, it occurs here as often as twenty-nine time- 
out of thirty. It is also occasionally met with on the thorax, 
abdomen, and limbs. It is peculiar in that it shows itself almost 
exclusively in women, being met with in men only in those pos 

* Loc. cit., p. 17-3. 

f Lecons sur la Syphilis, etudiee plus particulierement chez la Femme 
Pari>. 1873, p. 422. 

t Amer. Jour, of Med. Sci., April, 1878. 

\ Chicago Med. Jour, and Exam., Oct. 1878. 



SYPHILODERMA. 521 

ing thin, transparent, delicate skins. It is encountered during the 
latter half of the first and in the second year of the disease, and 
is a rare manifestation. It is much commoner in France than in 
this country. 

Its course is slow. It may continue two or three months or 
from one to two years. It is uninfluenced by antisyphilitic treat- 
ment, neither mercury nor iodide of potassium having any effect 
in causing its disappearance. Notwithstanding this peculiarity, 
the manifestation is, according to both Hardy and Fournier, 
unquestionably due to syphilis. Fox regards it as of syphilitic 
origin, but not as a direct manifestation of syphilis, and hence 
considers that it should not be classed among syphilitic lesions. 
In nature it is a simple pigmentary formation, probably differing 
in no way from chloasma. It may be mistaken for chloasma 
uterinum, vitiligo, and tinea versicolor. From the latter disease it 
may be known by its having a smooth, non-desquamative surface. 

Syphiloderma Pustulosum. — (Syn., Pustular Syphiloderm ; 
Pustular Syphilide ; Syphilis Cutanea Pustulosa.) The pustular 
syphilodermata constitute a large and important group. Although 
not so common as the erythematous and papular manifestations, 
they are nevertheless very frequently encountered. They appear 
in a variety of forms, the lesions of which differ in size, shape, 
number, distribution, and other features. Before describing these 
in detail I shall speak of them as a group. 

The pustules vary greatly in size. They may be no larger than 
a millet-seed, or, on the other hand, they may be split-pea sized 
or as large as a finger-nail. In shape they likewise vary ; at times 
they are circular, in other cases they are ovalish or irregular in 
outline. In form they are acuminated or rounded, as in acne 
and variola, or flat, as in ecthyma. They may be seated upon dis- 
tinctly indurated papular bases or surrounded by extensive areolae, 
in which latter event they are but little elevated above the level of 
the surface. They vary greatly as to number ; they may be few or 
very numerous. They may, moreover, be disseminated or grouped ; 
usually they are dispersed over the surface without regularity of 
distribution. They either begin as pustules, or, beginning as pap- 
ules, vesicles, or vesico-pustules, sooner or later become pustules, 
which in a variable time terminate in crusting. From the decided 
inclination to crust which the larger pustules evince early in their 



522 NEW GROWTHS. 

course, they have been termed " pustulo-crnstaceous" lesions. The 
crusts usually begin to form shortly after the lesions manifest them- 
selves, but sometimes they form simultaneously with the pustules. 
As a rule, the larger the pustule, the sooner will the process of 
crusting begin. The crusts either correspond in size and shape 
with the pustules which have preceded them, or they may be con- 
tracted and smaller than the original lesion. They may be acumi- 
nated or broad ; raised and bulky or flat and superficial. In con- 
sistence they are either soft, or, as is usually the case, firm or hard. 
The larger and more bulky crusts incline to become stratified, like 
the exterior surface of an oyster-shell. In color they vary from 
yellow to brown or even black, and when of any size and depth 
incline to assume an olive-greenish hue. Beneath the recent crust 
there always exists an ulcer; this may be superficial or deep, ac- 
cording to the general character of the primary lesion. The edges 
are usually sharply defined, giving the lesion a punched-out appear- 
ance. The base i- generally covered with an abundant, grayish, 
yellowish or greenish, puriform secretion. The pustular lesions 
are followed by pigmentation, and usually by marked cicatrices. 
A- regards the time at which they manifest themselves, they may 
be either early or late eruptions. They may be benign or malig- 
nant. The following varieties may be described : 

Small Acuminated Pustular SyphUoderm. — (Syn., .Miliary Pus- 
tular Syphiloderm.*) 

The pustules are millet-seed in size. They are raised above 
the level of the skin, and are seated upon small or minute, red- 
dish, papular elevations. They are acuminated in form, and 
contain an exceedingly -mall amount of fluid, more or less puri- 
form in character, which in time dries into adherent yellowish 
crusts. After the- crust has fallen off, -light desquamation or ex- 
foliation is apt to take place, which usually manifests itself in the 
form of a delicate, thin margin or fringe of epidermis around 
the base of the lesion, constituting a grayish ring or collar, the 
so-called "collerette" of the French. The hair-follicles are com- 
monly involved, the hairs penetrating through the centre of the 
lesions. 

The eruption is almost always abundant, the pustules existing 

* Herpetiform Syphilide of the French. 



SYPHILODEEMA. 523 

in great numbers, either discretely or confluently, irregularly dis- 
seminated or in groups, over various regions. Sometimes they are 
arranged in the form of more or less well defined circles and semi- 
circles. It usually invades a large tract of surface ; at times, how- 
ever, it is localized, as often occurs in the case of a relapse. The 
extremities, especially the arms and thighs, the chest, and the back 
are its favorite localities. With the eruption are usually found 
miliary papulo-pustules and papules ; not infrequently these are 
numerous, and show the various stages of the evolution of the 
pustule from the papule. Miliary vesicles, as well as large flat 
papules, may also be present. 

The miliary pustular syphiloderm may occur either as the 
earliest eruption, six weeks after the initial lesion, accompanied 
with fever and other general symptoms ; or, as a later secondary 
manifestation. Relapses may occur. It disappears leaving a deep 
pigment deposit of a purplish or brownish color. After the lesions 
have passed away, minute pin-point or pin-head depressions in the 
skin remain, which in time generally become effaced. The diag- 
nosis is not difficult. Other symptoms of syphilis usually accom- 
pany the eruption. 

Large Acuminated Pustular Syphiloderm. — (Syn., Acne-form 
Syphiloderm; Acne Syphilitica; Variola-form Syphiloderm.) 

The eruption is characterized by small or large split-pea sized, 
more or less acuminated pustules, similar in general features to 
those of simple acne, or of variola. The crusts, which form sooner 
or later, are yellowish or brownish yellow in color, small and thin 
or bulky, and seated upon superficial ulcers. It may develop 
itself rapidly with fever, or slowly. In the first case the small 
red spots rapidly become papular and then pustular, the lesion 
reaching its full development within from twenty-four to forty- 
eight hours. In the subacute form the lesions for several days 
look like papules upon the summits of which a minute quantity 
of pus slowly forms. In the acute form the lesions usually occur 
in large numbers, and are generally disseminated. In the sub- 
acute form the lesions are less numerous, more localized, and more 
likely to be grouped than in the acute form. They are met with 
upon the scalp, face,* and trunk ; more rarely upon the extremi- 

* See Plate V in my Atlas of Skin Diseases. 



524 NEW GROWTHS. 

ties. Other syphilitic lesions are apt to be present, as, for example, 
papules. 

It is one of the earliest of the pustular syphilodermata, and, as 
a rule, pursues a rapid and benign course. It is one of the rarer 
manifestations. I have encountered it more often in the colored 
than in the white race, and in either race chiefly in hospital prac- 
tice. It is to be distinguished from acne, from the eruption of 
the iodide of potassium, and especially from variola, for which it 
is frequently mistaken. In the colored race it not infrequently 
closely resembles variola, and the diagnosis is often difficult. In 
doubtful cases a few days should be allowed to pass before pro- 
nouncing an opinion. 

Small Flat Pustular SyphUoderm. — (Syn., Impetigo-form Syph- 
iloderm; Impetigo Syphilitica; Pustular Eczema-form Syphi- 
loderm.) 

The pustules are generally small, flat, and grouped into an 
irregularly-shaped patch. Crusting begins almost immediately, 
rendering the lesions markedly pustulo-crustaceous. The crusts 
lire more or less adherent ; and are thick, bulky, uneven, and ir- 
regularly heaped up. They are dry, and incline to become granu- 
lar and to crumble. In color they are yellowish, greenish yellow 
or brownish yellow, resembling the crusts of pustular eczema. 
Where the pustules have coalesced, a continuous sheet of crust is 
apt to form, as in pustular eczema. The ulcer beneath the crust 
may be superficial or deep. 

The eruption is usually encountered about the face, especially 
around the nose and mouth and on the hairy parts of the lace, on 
the scalp, and around the genitalia. It is generally benign; but 
it may assume a malignant action, the ulceration extending deeply, 
and spreading over considerable surface in a more or less ser- 
piginous manner. The affection resembles pustular eczema, and 
may readily be confounded with it, especially on the scalp, if the 
character of the erosion or ulcer be not taken into consideration. 
The diagnosis can scarcely be made from the appearance of the 
crust. 

Large Flat Pustular Syphiloderm. — (Syn., Ecthyma-form Syph- 
iloderm ; Ecthyma Syphiliticum.) 

This appears in the form of large, finger-nail sized, flat pus- 
tules, seated upon a deep-red base. The pustules seldom remain 



SYPHILODERMA. 525 

as such for any length of time, but incline to crust immediately. 
Two varieties are met with, the superficial and the deep. In the 
former the crust is flat, roundish or oval, adherent, and of a yel- 
lowish-brown or dark-brownish color. It is seated upon a super- 
ficial ulcer or erosion, having a grayish or yellowish, abundant 
secretion. The lesions are usually numerous, and may appear upon 
any part of the body, although they have preference for the back, 
shoulders, and extremities.* It is one of the commoner pustular 
manifestations, and runs a benign course. It is apt to occur in 
the first year, and generally after the sixth month. 

The deep variety possesses a raised and more bulky crust, which 
inclines to become conical, is harder in consistence, and has a dark- 
greenish or blackish color, and when prominent and stratified, in 
the form of an oyster-shell, constitutes the condition known as 
eupia. This form of crust, it must be remembered, is also met 
with in connection with the bullous syphiloderm. Rupia, there- 
fore, may be the result either of the pustular or of the bullous 
eruption. Beneath the crust the ulcer is seen to be excavated, 
defined in outline or punched-out in appearance, and to be covered 
with an unhealthy, greenish-yellow, puriform secretion. It is a 
late and malignant manifestation. In my experience, it is seldom 
met with outside of hospital practice. 

Syphiloderma Tuberculosum. — (Syn., Tubercular Syphi- 
loderm; Tubercular Syphilide; Syphilis Cutanea Tuberculosa.) 
The eruption here consists of one or more solid elevations of the 
skin, varying in size from a split pea to a hazel-nut. They are 
circumscribed, rounded in form, acuminated or semiglobular, and 
have usually a smooth, often glistening surface. They are firm 
to the touch, and are deeply seated in the skin and subcutaneous 
connective tissue. In color they are deep red or brownish red, 
and at times they have a dull yellowish-red or distinctly copper 
tint. Sometimes they have an intensely smoky-red hue, a color 
not met with in any other disease of the skin. 

They may be either single or multiple, usually the latter, al- 
though they rarely occur in great numbers. If small, they are 
more apt to be numerous. They seldom appear over the whole 
body, but are generally confined to certain regions. They may be 

* See Plate D in my Atlas of Skin Diseases. 



526 



NEW GROWTHS. 



either disseminated or grouped ; when in large numbers they tend 
to form more or less solid tubercular patches. As to their ar- 
rangement, they may be either irregularly disposed or grouped in 
the form of segments of circles and semicircles. When the latter 
arrangement occurs, the patches are very apt to coalesce, forming 
a serpiginous tract of disease, the eruption being known as the 
serpiginous tubercular SYPHILODerm. The regions com- 
monly invaded are the various parts of the face, the°back, and, 
more rarely, the extremities. 

They are, as a rule, unaccompanied by pain, heat, or itching. 
Their development is slow, usually extending over weeks or 
months. They are in the majority of cases a late manifestation, 
rarely showing themselves before the second year, and generally 
not until later. Not infrequently they do not appear until live, 
ten, or even twenty years after the initial lesion. Other symp- 
toms of the disease will almost invariably have occurred before 
they manifest themselves. 

They disappear in two ways, by absorption or ulceration. They 
may ulcerate superficially or deeply,— usually the latter. The 
process may begin upon their summits or in their interior, the re- 
sult being a more or less complete destruction of the lesions. The 
ulcer is usually a deep, punched-out cavity, with irregular edges, 
horseshoe or crescentic in shape, covered with a grayish, yellowish 
deposit of gummy matter, or with a brownish crust. Ulceration 
may also attack a patch <>f grouped tubercles, the result being an 
extensive excavation, involving at times the whole affected surface. 
Not infrequently the pro.,— assumes a serpiginous course, extend- 
ing itself in an irregular, more or less serpentine manner. The 
ulceration here is usually accompanied by a certain amount of 
simultaneous cicatrization, and is apt to be disfiguring in its results. 
It is often encountered on the back, and is generally obstinate. 

Papillary formations at times spring up from ulcerating tuber- 
cles, in the form of wart-like, cauliflower excrescences, accompanied 
by the secretion of a yellowish, puriform, offensive product, consti- 
tuting SYPHILIS CUTANEA PAPILLOMATOSA. The entire scalp 
may be invaded by this eruption, and it is probable that many 
cases of the so-called framboesia of older writers were aggravated 
instances of this variety of syphilis. The same form of growth 
may occur with the gummatous ulcer. 



&YPHILODERMA. 527 

The tubercular syphiloderm is to be diagnosed from lupus vul- 
garis, from lepra, and from carcinoma. It is most liable to be 
confounded with lupus vulgaris. The tubercles of syphilis, how- 
ever, are firmer, more deeply seated, and have a history of more 
rapid development. Lupus, moreover, appears usually first in 
childhood, while the tubercular syphiloderm is rarely seen before 
adult or middle age. 

Syphiloderm a Gummatosum. — (Syn. } Gummatous Syphilo- 
derm ; Gummatous Syphilide ; Syphilis Cutanea Gummatosa.) 
This is characterized by a more or less circumscribed formation 
situated in the subcutaneous tissue, showing its presence upon the 
surface as a slightly raised, rounded, or flat tumor, variable as to 
size. It is of moderately firm consistence, but tends iu its course 
to break down. It is known as a "gumma," "gummy tumor," 
or " syphiloma." It usually begins as a small, pea-sized, soft, ill- 
defined, painless body, which is felt to be beneath the skin. The 
skin at this time is not altered in color, nor is the outline of the 
growth discernible. The deposit increases slowly in volume, until, 
through a period of weeks or months, it gradually assumes definite 
shape and consistence. It is now seen to be a more or less rounded 
tumor embedded in the subcutaneous tissue. The skin becomes 
involved and appears pinkish or reddish. In size it may vary 
from a hazel-nut to a walnut or larger. In shape it shows itself 
as a slightly elevated, semiglobular or flat, uniformly organized 
body. To the touch it has a soft, doughy, somewhat elastic feel. 

Gummata rarely exist in numbers. One or two only are, as a 
rule, present; occasionally they are multiple, but such instances 
-are of infrequent occurrence. In exceptional cases, where they 
appear during the early years of the disease, they may be both 
numerous and symmetrical, and accompanied by well-marked 
local and general symptoms. They may appear upon any part 
of the body ; their tendency, however, is to develop in the looser 
and softer tissues, as upon the flexor surfaces of the extremities, 
abdomen, and sides of the thorax. The palms and soles are 
rarely attacked. 

The gumma tends to break down, ulcerate, and destroy the 
tissues in which it has its seat. The ulcer is a circumscribed, deep 
excavation, usually rounded in form, with abrupt, perpendicular 
edges. It may be the size of a finger-nail or as large as the palm 



528 NEW GROWTHS. 

of the hand. Its bottom is generally uneven, and is covered with 
a grayish-red gummy deposit. The skin is always completely 
destroyed ; likewise, to a great extent, the subcutaneous connec- 
tive tissue and sometimes the deeper structures. Disintegration 
may progress rapidly or slowly. The loss of tissue is often great, 
although cicatrization usually takes place in such a manner as to 
leave a comparatively insignificant scar. In place of ulceration, 
the growth may disappear by absorption. 

The gumma is to be distinguished from furuncle and from 
abscess; from enlarged lymphatic glands; from carcinoma; and 
from fibrous and fatty tumors. The ulcer will be diagnosed from 
the non-syphilitic ulcer by its history, depth, sharply defined edges, 
and punched-out appearance; by the character of the secretion, 
the absence, as a rule, of pain, and the presence, in many cases, 
of other symptoms of syphilis. 

SYPHILODERMA BUJLLOSUM. — {Si/n., Bullous Syphiloderm ; 
Bullous Syphilide; Syphilis Cutanea Bullosa; Pemphigus Syph- 
iliticus.) The eruption is characterized by blebs containing a clear, 
watery fluid, which tends to become soon cloudy and thick. At 
times the lesions even in the beginning partake more of the nature 
of pustules than of blebs. In size they vary from a pea to a wal- 
nut. They are discrete, disseminated, circular or ovalish in form, 
and are surrounded with a slight areola. They may be fully or 
only partially distended, but after lasting a variable time they 
break, the contents drying into yellowish, brownish, or dark- 
greenish crusts. 

The crusts vary considerably in form : at times they are large, 
bulky, and raised ; in other cases they are conical, and furrowed 
upon their surface like the outside of an oyster-shell, the for- 
mation being known as rupia. (See Large Flat Pustular Syph- 
iloderm.) In other cases they are smaller, flatter, and less bulky. 
Beneath the crusts, which may usually be removed without diffi- 
culty, are seen erosions or ulcers, with sharply defined edges, se- 
creting a greenish-yellow fluid. They are followed by more or 
less pigmented cicatrices. The course of the eruption is variable, 
depending materially upon the general condition of the patient. 

It is a late manifestation, and is usually accompanied by other 
symptoms of the disease. It is rare, aud is seen for the most part 
upon cachectic, broken-down individuals. It also occurs in the 



SYPHILODERMA. 529 

new-born, as the result of inherited syphilis, when it often closely 
resembles pemphigus vulgaris. (See Hereditary Syphilis.) The 
character of the blebs and of the subsequent crusts will serve to 
distinguish it from pemphigus ; other signs of syphilis, moreover, 
will usually be noted. 

Syphiloderma HiEREDiTARiUM Infantile. — The cutaneous 
manifestations of hereditary syphilis in the infant present a some- 
what different appearance from those of acquired syphilis, and are 
therefore entitled to separate description. 

Syphilis in the new-born may be hereditary ; that is, the child 
may have become infected in utero through the influence of the 
mother or father, or of both parents ; or it may be acquired, the 
disease being contracted at any period after leaving the uterus, 
either during delivery or after birth. When acquired, it runs 
precisely the same course as in the adult. The terms "congeni- 
tal" and "infantile" syphilis are indefinitely used to express the 
existence of the disease, without reference to its having been in- 
herited or acquired. The distinction, however, should if possible 
be made. 

A child the subject of hereditary syphilis may be born either 
apparently sound or in an obvious state of disease. The majority 
of syphilitic infants are born to all appearances healthy, the dis- 
ease not showing itself until a later period, — in almost all cases, 
however, within the first three months. According to Diday,* 
who has collected 158 reported cases of hereditary syphilis in in- 
fants, the disease manifested itself before the end of the first 
month after birth in 86 cases, and before the completion of the 
second month in 45 cases, while in the third month there were but 
15 cases. It will be seen from these statistics that the disease 
usually makes its appearance before the end of the second month, 
and that after the fourth month the chances are in favor of the 
child having escaped infection. On the other hand, infants may 
come into the world with the imprint of syphilis stamped upon 
them in the form of the maculo-papular or bullous eruption, or 
with the general signs of syphilitic cachexia and marasmus. 
These cases rarely live longer than a few days or weeks. 



* A Treatise on Syphilis in New-born Children and Infants at the Breast, 
p. 101, New Syd. Soc. Trans. London, 1859. 

34 



530 



NEW GROWTHS. 



When the child is born with a clean skin and apparently healthy, 
syphilitic symptoms are not apt to manifest themselves before the 
second or third week, and often not until later. The child during 
this period either remains well or shows signs merely of general 
debility. At birth the infant may be stout and well nourished, or 
spare, puny, and delicate. Usually in the course of two or three 
weeks it begins to exhibit unmistakable evidence of failing in 
health. It grows thinner and weakly, is fretful, or cries peevishly, 
wastes away, and becomes greatly changed in appearance. From 
a well-nourished infant it has in a short time become emaciated 
and plainly diseased. The skin assumes a peculiar dingy, yellow- 
ish, earthy or muddy hue. The cutaneous tissues are deprived of 
their fat; the bones are prominent; while the skin is harsh, dry, 
thin, and more or less wrinkled, forming lines and furrows, which 
are apt to be particularly noticeable about the face. These changes 
give to the little patient a pinched, wizened appearance, resembling 
that of an old man or woman. 

One of the first specific symptoms noticed is coryza, which is 
usually present at this stage of the disease. The discharge at first 
is thin and watery, but becomes thicker and tenacious, gradually 
accumulating in the nasal passages. In a short time the oarea 
become stopped up, slight crusting taking place around the orifices; 
the breathing is interfered with; and a peculiar snuffling noise is 
heard, which is characteristic. At times the nostrils are occluded 
to such an extent that breathing can take place only through the 
mouth, in which event it is with difficulty that the child is able to 
suck. Later, the discharge from the nares becomes more or less 
sanious and has a penetrating, fetid odor, and mucous patches 
appear about the nares and around the mouth. If the disease 
continue, the small bones of the nose may be involved, caries 
occurring, with discharge of fragments of bone, followed In- de- 
formity of the nose. With the coryza there is generally more or 
less hoarseness, and at times even aphonia, the throat being 
attacked in a similar manner by erythema and mucous patches. 
The cry of the child at this stage of the disease is peculiar. 

The lesions upon the skin may manifest themselves before the 
coryza, simultaneously with it, or later; usually they appear at 
about the same time. Not rarely, however, the skin is the first 
tissue attacked. The eruption may appear in the form of ery- 



SYPHILODERM A. 531 

thema, maculo-papules, papules, or blebs, or as a mixture of these 
lesions. The most frequent manifestation consists of both macules 
and papules. Not infrequently the first cutaneous symptoms are 
erythematous patches varying in size from a finger-nail to the palm 
of the hand, occupying the buttocks, thighs, or genitalia. They 
are irregularly shaped ; have a more or less indistinct outline; are 
yellowish, brownish red, or coppery in color ; and are somewhat 
shining or are covered with a thin, wrinkled epidermis. They are 
either dry or squamous or slightly moist and excoriated. At times 
the patches are extensive and involve the whole of the lower 
portion of the trunk and the thighs in one continuous sheet of 
erythema. The coloring in these cases is not infrequently of an 
intense, deep yellowish red. The early stage of this manifestation 
often closely resembles simple erythema intertrigo, so much so that 
the diagnosis may be difficult. It may also resemble erythematous 
eczema, and an opinion should not be expressed hastily. In a short 
time the lesions become more marked, the patches become thick- 
ened, and distinct macules appear here and there over the surface, 
which either remain such or pass into flat papules. In other 
cases the palms and soles are first attacked by the erythema, the 
epidermis beginning at once to exfoliate in the form of thin, dry, 
ragged pieces or layers. It will thus be noted that the erythe- 
matous syphiloderm of hereditary syphilis differs considerably in 
appearance from that of acquired syphilis. 

Usually in the course of a few weeks the erythematous patches 
become the seat of broad, flat papules, the size of a split pea or 
finger-nail, the eruption thus becoming maculo-papular. This may 
be considered as the commonest syphiloderm in the infant. The 
papules exist as both dry and moist lesions, the latter form pre- 
dominating, especially about the genitalia and natural folds of the 
skin. They are usually large, not infrequently of the character 
rather of patches of infiltration ; often but slightly raised above 
the level of the surrounding skin ; and are smooth and glazed, or 
are covered with a pellicle or scale. 

The moist papule, or mucous patch, is one of the earliest 
symptoms of hereditary syphilis; it is also one of the commonest 
manifestations. These lesions first make their appearance about 
the nose, mouth, anus, and genitalia. They are also frequently 
met with about the toes and fingers, umbilicus, axilla?, backs of 



532 NEW GROWTHS. 

the ears, and in other natural furrows of the integument, particu- 
larly where friction, heat, and moisture are apt to exist. Together 
with moist papules occur fissures, secreting a viscid or sanious 
product, which tends to crust and to mask the true lesion. Pap- 
ules, moreover, not infrequently excoriate, break down, and ulcerate 
superficially. 

Mucous patches occurring in the mouth may be confounded 
with aphthae, or thrush, which often bears a close resemblance to 
the syphilitic lesions. Aphthae may be distinguished by being 
seated upon an inflammatory base, and by their oval or circular 
shape with distinct margins and areolae. They usually occur in 
successive crops and in groups, and are, moreover, generally at^ 
tended by gastric derangement. The affection is due to a vege- 
table parasite, the o'idium albicans, which may be demonstrated 
under the microscope, thus, in doubtful cases, determining the 
diagnosis. 

The bullous syphiloderm in the infant usually manifests itself 
at birth. It may, however, first show itself later. It consists of 
variously sized, disseminated, flat or semiglobular, circular, ovalish, 
or irregularly-shaped, distended or flaccid blebs. They possess a 
decided disposition to attack the palms and soles, the fingers and 
toes, and the limbs. They show no regularity of form, and are 
usually present in all stages of development. Their contents 
may be clear, cloudy, or sanious. They are seated upon reddish, 
unhealthy-looking skin, and are sometimes surrounded by slight 
areola?. They may be present in large numbers, or they may be 
sparse. Sooner or later they break, or are ruptured by violence, 
and show an excoriated or ulcerated reddish base, which is slow to 
take on reparative action. At times the lesions break down into 
ulcers, which are not infrequently met with on the joints of the 
fingers and toes. 

The course of the eruption varies with the general condition 
of the patient. New blebs are apt to come out from time to time, 
while the older ones become pustular, rupture, and are succeeded 
by excoriated, unhealthy-looking surfaces. Other cutaneous le- 
sions, as moist papules and patches about the genitalia and other 
regions, mucous patches in the mouth, fissures and discolorations 
of the skin, are also usually present ; in some cases, however, the 
blebs are the only skin lesions encountered. Other general symp- 



SYPHILODERMA. 533 

toms of the disease may almost always be found. The bullous 
syphiloderm in the infant is a grave manifestation, the patient 
rarely surviving. 

Pathology. — The anatomy of the syphilodermata has received 
careful investigation by Auspitz,* Neumann,f Biesiadecki,| and 
Kaposi.§ The typical syphilitic deposit, as encountered in the 
papule and in the tubercle, is a new growth, consisting of a small 
round-cell infiltration, resembling that of lupus vulgaris. The 
earliest manifestation of syphilis upon the skin, the erythematous 
syphiloderm, is characterized by hyperemia with incipient pro- 
liferation of connective-tissue cells. The process in this stage does 
not show the specific cell infiltration, this latter first appearing 
with the papule. The capillaries are chiefly involved in the pro- 
duction of the macule, a proliferation of connective-tissue corpus- 
cles taking place along the walls of the vessels. 

The papule presents a marked deposition of the syphilic mate- 
rial. In the flat papule it has its seat in the mucous layer of the 
epidermis, in the papillary layer of the corium, and in the body of 
the corium extending down as far as the subcutaneous connective 
tissue. The extent and depth of the infiltration vary with the 
size of the papule. The infiltration is circumscribed and sharply 
defined both laterally and from the tissues, beneath. It is made 
up of a more or less solid mass of disseminated, numerous, small, 
round cells, which vary considerably in size and in other charac- 
teristics. They show no regularity of distribution, but appear 
for the most part closely packed together, here and there, within 
the meshes of the connective tissue. In some cases they are so 
numerous as almost completely to obliterate all signs of the normal 
structures. In the process of absorption, which takes place as the 
papule is about disappearing, the central portion is first absorbed, 
the papule in this stage assuming a somewhat cup-shaped or 
scooped form. 

* Mediz. Jahrbuch, Bd. ii., 1864, Wien. " Ueber die Zelleninfiltration der 
Lederhaut bei Lupus, Syphilis und Scrofulose." 

f Lehrbuch der Hautkrankheiten, p. 448. Wien, 1873. 

J Beitrage zur phys. und path. Anat. der Haut. Sitzb. d. mathem.-naturw. 
CI., Bd. lvi., Abth. ii. Wien, 1867. 

\ Die Syphilis der Haut und der angranzenden Schleimhaute. Wien, 
1874-75. 



534 NEW GROWTHS. 

According to Kaposi, in the moist papule, or flat condyloma, 
there is the same infiltration occupying the same structures and 
extending itself occasionally into the subcutaneous layers. It is 
likewise sharply defined as to outline. The papillae here are 
decidedly enlarged, swollen, and lengthened into finger-like pro- 
longations, and at times formed into two or more club-shaped 
extremities. The mucous layer is also highly developed and much 
thickened. 

The pustule, like the papule, is also well defined, the deposit 
occupying the corium, and, in some instances, the subcutaneous 
connective tissue. According to the size, character, and stage of 
the pustule will the appearances of tlie infiltration be somewhat 
different. As stated by Kaposi, the essential features of the pus- 
tule consist in the presence of dimly-contoured, highly granular, 
cloudy, nucleated cells and free nuclei within the uppermost layer 
of the corium, papillary layer, and rete, seated in a succulent, 
large-meshed, serum-saturated tissue or even in open spaces. The 
tubercle and gumma present the same characters as the papule, the 
infiltration extending itself, however, more widely and deeper into 
the cutaneous tissues. The elements concerned are the same as in 
the papule. The extent to which the formation is circumscribed, 
and the depth of the infiltration, will of course depend upon the 
size and form of the growth. The deposit ultimately disappears 
either by absorption or by ulceration. 

Treatment. — The treatmenl of the syphilodermata is that of 
syphilis, the manifestations upon the skin being but one group 
of the many symptoms which take place in the evolution of the 
disease. For a complete exposition of the treatment of the dis- 
ease, the reader is referred to the admirable works of Fournier,* 
Bumstead and Taylor,i and Keyes.J 

Constitutional Treatment.— In entering upon the treat- 
ment of syphilis, the importance of a systematic course of medi- 
cine, the length of time required to bring about the best results, 
the nature of the disease, the tendency to relapses, and the ad- 



* Lecons sur la Syphilis etuuiee plus particulierement chez hi Femme. 
Paris, 1873. 

f The Pathology and Treatment of Venereal Diseases. Phila., 1879. 

| The Tonic Treatment of Syphilis. New York, 1877. See also Phila. 
Med. Times, Feb. 2-5, 1882. 



SYPHILODERMA. 535 

vantages of prolonged treatment, should all be clearly stated to 
the patient. 

It is, in the first place, a matter of considerable moment that 
the patient be brought under the most favorable hygienic influ- 
ences. The general health is to be carefully looked after through- 
out the entire course of treatment. The benefits to be derived 
from leading a regular life should be impressed upon the indi- 
vidual. The mind should not be suffered to dwell upon the dis- 
ease. In the case of men, the use of tobacco and spirituous drinks 
should be interdicted, or at least they should be made use of only 
with the sanction of the physician. Fresh air, proper exercise, 
relaxation from business, and healthy out-door amusements are to 
be sought for. Attention to cleanliness is to be enjoined. Baths, 
in the form of the cold douche or vapor, are useful. The latter 
especially, indulged in not too frequently, is often a decided ad- 
juvant in the treatment. The diet should be directed by the 
physician, and should consist, as a rule, of the most nourishing 
articles, together with wine or malt liquor, as may seem neces- 
sary. The bowels demand attention, and if constipated should be 
kept open by means of one or another of the natural saline ape- 
rient waters or by small doses of aloes. In a word, everything 
should be done to assist nature in coping with the disease. 

The two specific remedies employed in the treatment are mer- 
cury and iodide of potassium. They are the only two remedies 
that have a direct action on the disease, and their value is ines- 
timable. Of the two, mercury is the more valuable. They are 
employed either alone or in combination, the indications for the 
use of one or the other, or for their conjoint use, being found in 
connection with the age of the disease, the character of the erup- 
tion, and the general condition of the patient. I would here state 
that mercury is a safe remedy, and when employed judiciously 
may be used without fear of evil consequences. It may be ad- 
ministered in small doses for one, two, or three years without 
injury to the general health. In this connection it need scarcely 
be remarked that when given for a long period continuously it is 
essential that the dose be small, and that salivation be at no time 
induced. The aim should be to obtain the tonic and not the toxic 
effect of the remedy. 

It may be introduced into the system in a variety of ways. 



536 NEW GROWTHS. 

The usual method, and without doubt the best for the majority of 
cases, is by the mouth. Patients vastly prefer to be treated by 
this plan, for obvious reasons ; it is, moreover, the most practical 
method of treatment. A number of the preparations of mercury 
are made use of; blue mass, calomel, corrosive sublimate, gray 
powder, the protiodide, the biniodide, and the bicyanide, all enjoy- 
ing reputation. The most active and energetic preparations are 
the mild chloride and the protiodide. The system may be brought 
under the influence of the mineral more rapidly by calomel than 
by any other preparation: hence it is valuable where an immediate 
effect is demanded, as, for example, where there is grave iritis or 
serious throat disease. It may be given in one or two grain doses 
with a quarter or a third of a grain of opium, three or four times 
daily. A more rapid effect even is to be obtained from oft-repeated 
minute, fractional grain doses, as an eighth or a twelfth of a gram 
every hour. The system is usually brought under its influence 
by this latter method in two or three days. 

The protiodide is the remedy perhaps in most general use at the 
present day. It is given in sixth, quarter, third, or half grain 
doses, three times daily, usually with extract of lactucarium, hy- 
oscyamus, or gentian, and in pill form. It may also be adminis- 
tered in the form of granules, the centigramme (containing about 
one-seventh of a grain) granule being a convenient strength. 
Those made by Gamier and Lamoureux arc reliable. It is an 
active preparation, and at times is irritating. Not infrequently, 
when taken for some time, it induces gastric and intestinal derange- 
ment, griping pains, and diarrhoea. These symptoms, however, 
may be counteracted in a great measure by the simultaneous use 
of opium or hyoscyamus. 

Blue mass and gray powder are both mild and comparatively 
slow in their action, and are valuable preparations. They are 
among the least irritating of the mercurials; this is especially 
true of the latter. Gray powder is the most desirable of all the 
mercurials for infants and children. The dose for adults is from 
one to three grains thrice daily; for infants, half a grain or less, 
twice daily. Quinine may be advantageously combined with it. 
Bumstead and Taylor speak well of the blue pill with iron and 
opium in the early syphilodermata, as in the following prescrip- 
tion : 



SYPHILODEEMA. 537 

R Pilulee Hydrargyri, J)ii ; 

Ferri Sulphatis Exsiccati, T)i ; 

Extracti Opii, gr. v. 
M. Ft. in pil. no. xx. div. 
Sig. — One pill three times daily after meals. 

The corrosive chloride acts slowly, and, as a rule, is well borne, 
manifesting comparatively little disposition to salivate ; it is per- 
haps the least active of all the preparations. It has comparatively 
little effect in subduing obstinate symptoms. When taken for a 
time, it tends to produce pains in the stomach and bowels. It is 
seldom employed in early syphilis, being generally used for the 
later manifestations. Where iron is called for, it may be advan- 
tageously combined with the tincture of the chloride of iron. It 
may be prescribed with water, alcoholic mixtures, vegetable tinc- 
tures or syrups, or may be given in pill form, thus : 

R Hydrargyri Chloridi Corrosivi, gr. i ; 

Saponis, q. s. 
M. Ft. in pil. no. xvi. div. 
Sig. — One pill thrice daily after meals. 

The dose is about one-sixteenth of a grain, three times daily. It 
may also be administered in cod-liver oil by first dissolving it in 
a few drops of sulphuric ether, as in the following prescription : 

5c Hydrargyri Chloridi Corrosivi, gr. i ; 
^Etheris Sulphurici, fgi. 

Solve et adde 
Olei Morrhuse, f^viii. 
M. — Sig. A tablespoonful contains one-sixteenth of a grain of the mercurial. 

If the bottle be kept tightly corked, it may be retained in solution 
for an indefinite time ; but if the ether be allowed to evaporate by 
exposure to the air, the corrosive sublimate will be precipitated 
and cannot be redissolved by the addition of more ether.* The 
bicyanide of mercury, in the dose of from one-twentieth to one- 
sixteenth of a grain, in pill form with gentian, quinine, or opium, 
was highly esteemed by Tilbury Fox,f who preferred it to the 
other preparations. 

* Bumstead and Taylor, loc. cit., p. 794. f Loc. cit., p. 306. 



538 NEW GROWTHS. 

Mercury is also introduced into the system by inunction. It is 
a valuable method of treatment, and is frequently most advanta- 
geously employed. Sigmund, who used mercurial inunctions in 
9379 cases occurring at the Vienna Hospital between the years 
1842 and 1855, regards this as the simplest and most efficacious 
mode of treating the various forms of syphilis.* It acts rapidly, 
and when pushed brings the system under the influence of the 
remedy in a short time. It is therefore useful in those cases 
where a speedy effect is desired ; in old cases of syphilis ; and 
where mercury is not well borne by the stomach. It constitutes 
the best method of treating the disease in the infant. The two 
preparations employed are mercurial ointment, and olcate of mer- 
cury, as suggested by Berkeley Hill. The chief objection to the 
use of inunctions by means of mercurial ointment is the staining 
of the linen. This, however, may be obviated in a measure by 
the employment of the oleate of mercury, used in the strength of 
from five to twenty per centum. Bumstead and Taylor prefer 
the twenty per centum preparation combined with an equal weight 
of simple cerate, which form- a consistent mass of a light fawn- 
color. The oleate is more apt to irritate the skin than the mer- 
curial ointment, and should therefore be used with greater caution. 
According to Keyes,f it is absorbed more easily than mercurial 
ointment, and therefore has more effect. In making the applica- 
tions, the more delicate portions of the skin, and those which are 
exposed to friction or motion or which are usually covered with 
hair, should be avoided. 

The frictions are made upon various regions, the arms, axillae, 
thighs, abdomen, chest, and back being the localities usually se- 
lected. Beginning with one or another of these regions, for ex- 
ample, the arms, the other parts are in turn taken up, when the 
parts that were first rubbed are again subjected to the process. 
The frictions are performed slowly, with the hand, the operation 
requiring from fifteen to thirty minutes or until the preparation 
used has been dissipated. Ordinarily they are made once in the 
twenty-four hours, the substance employed being allowed to remain 
on the skin for one or two days before being washed off. prepara- 



* Die Einreibungscur bei Syphilisformen. "Wien, 1878. 
f The Venereal Diseases. New York, 1880. 



SYPHILODERMA. 539 

tory to another rubbing. The skin should never be permitted to 
become irritated ; if such be the tendency, new localities must be 
selected, a weaker ointment employed, or the treatment by this 
method suspended. The requisite quantity for each friction is 
from a half to one drachm of the officinal mercurial ointment, and 
about a drachm of the ten or fifteen per centum oleate of mercury. 
For infants the mercurial ointment should be weakened by mixing 
with one, two, or more parts of lard. Salivation is to be guarded 
against. If this occur, the applications should be suspended, and 
the body cleansed with soap and water. The mouth and teeth 
should be kept clean by the use of the brush and an astringent 
lotion, and the bowels kept open. 

To obviate the objection to smearing the whole body with 
greasy matter and the consequent uncleanliness, Sturgis* directs 
the patient to bathe the feet thoroughly in hot water the night 
on which the first inunction is made, when half a drachm of the 
twenty per centum oleate of mercury is rubbed briskly into the sole 
of the right foot. This is repeated the next night on the left foot, 
and so on alternate nights the right and the left foot is anointed 
with half a drachm or a drachm of the preparation. The same 
stockings, which should be thick, are worn day and night for a 
week. At the end of this time the feet should be thoroughly 
cleansed with hot water and soap, and an intermission of three 
or four days allowed to elapse before renewing the process for a 
similar length of time. Iodide of potassium maybe given by the 
mouth meanwhile. One of the advantages of this form of -inunc- 
tion is that every movement the patient makes in walking serves 
to rub the ointment into the skin of the feet, thus permitting 
absorption to take place. 

Mercury may also be administered subcutaneously, by means of 
the hypodermic syringe and corrosive sublimate dissolved in water, 
with morphia. Lewinf employs for each injection a fluid con- 
sisting of about one-eighth of a grain of corrosive sublimate dis- 
solved in fifteen drops of water with one-tenth of a grain of acetate 

* The Student's Manual of Venereal Diseases. New York, 1880. 

j- Die Behandlung der Syphilis mit suhcutaner Sublimat-Injection. Berlin, 
1869. For further information, see interesting papers by Wiggles worth, Bos- 
ton Med. and Surg. Jour., Aug. 26, 1869 ; and Taylor, New York Med. Gaz., 
May 13, 1871. 



540 NEW GROWTHS. 

of morphia. The region selected for the puncture is usually the 
back. The operation is repeated once or twice daily. Bumstead 
and Taylor recommend this method in cases of early malignant 
syphilis in which deep ulceration occurs. Fifteen to twenty injec- 
tions usually suffice to remove the lesions. It is better to make 
the injections near the patch of disease to be removed, as a cer- 
tain local eifect is usually observed. Iodide of potassium may be 
given simultaneously by the mouth. Although experience has 
shown that this method may be employed in certain cases with 
good result, it has many disadvantages, chief among which are 
that it calls for much time on the part of both physician and 
patient; that it is painful; and that it is followed not infre- 
quently by subcutaneous abscesses, and by salivation. Patients, 
as a rule, object seriously to its use. 

The mercurial vapor bath is yet another method, and a valuable 
one. From twenty to thirty grains of calomel or thirty to sixty 
of the black oxide of mercury are used at each bath, which lasts 
about half an hour. The patient, with a long sleeveless flannel 
night-shirt reaching from the neck to the feet, and covered with a 
large rubber blanket, sits on a stool under which is the vaporizing 
apparatus, consisting of a plate having a gutter around its circum- 
ference to hold a little water and a hollow in the middle for the 
mercurial salt. An alcohol lamp under this is arranged to vapor- 
ize the water first, throwing the patient into a profuse perspiration, 
the mercury being volatilized later, and so readily absorbed by the 
skin. The patient remains covered until he cools off, and then 
goes at once to bed in his flannel shirt, The plan is cleanly and 
of easy application. Bumstead and Taylor, Keyes, and Sturgia 
are all warm advocates of this mode of administering the remedy, 
and to their writings I refer the reader for a further description 
of the procedure. For infants the corrosive sublimate bath is 
serviceable. It is prepared in the strength of from ten to thirty 
grains to an infant's bathtubful of warm water. The patient is 
allowed to remain in the bath for twenty minutes. 

The selection of one or another of the methods mentioned for 
administering mercury must depend upon the requirements of the 
case under consideration, as well as upon other circumstances. 
The age of the patient is to be taken into account ; in infants and 
young children, for example, the best results are to be obtained 



SYPHILODERMA. 541 

from inunction and the mercurial water bath. The general health, 
whether stout or weakly and debilitated ; the condition of the 
alimentary canal; and the occupation of the patient, are to be 
borne in mind. The rapidity with which it is considered to be 
desirable to bring the system under the influence of the remedy, 
also whether the patient is to be under continuous observation, 
or is to be seen only at intervals or irregularly, must decide in 
favor of one or another method. Throughout the treatment it is 
of importance to look to the health of the patient. To secure 
good results it is essential that a high standard of general health 
be maintained during its employment. In the majority of cases, 
therefore, tonics are called for, the preparations of iron, arsenic in 
small doses, quinine, gentian, and like remedies, all being valuable 
adjuvants in the treatment. 

The various vegetable infusions, decoctions, and fluid extracts, 
as those of sarsaparilla, mezereon, guaiacum, dulcamara, and 
stillingia, may here be mentioned. They act as diaphoretics, 
cathartics, and tonics. Their chief value is in syphilis of long 
standing, in severe and obstinate cases, and in subjects broken 
down and debilitated by the abuse of mercury or from other 
causes. The general condition not infrequently improves mark- 
edly under their continued use. They are to be viewed as alter- 
atives and tonics. They may be given alone, or conjointly with 
mercury or iodide of potassium, the most efficacious preparations 
being Zittmann's decoction and the compound decoction of sarsa- 
parilla. 

Opium remains to be referred to as a remedy. Great benefit in 
some cases is to be derived from its use. It is particularly valu- 
able in the treatment of the ulcerative lesions. The progress 
of destructive ulcerations may often be arrested by opium after 
all other means have failed. I have not infrequently seen excel- 
lent results from its use. It may be prescribed in doses varying 
from half a grain to two grains, three times daily, or, in the case 
of the extract of opium, half the quantity. As a rule, patients 
tolerate large doses. The mineral acids, especially nitric acid, 
may also be prescribed with advantage in the later stages of the 
disease. 

The length of time which mercury is to be employed must rest 
with the case under consideration : no positive rule can be laid 



542 



NEW GROWTHS. 



down. I would, however, remark that in the vast majority of cases 
the remedy is continued for much too short a time. Were its use 
continued for a longer period, perhaps in smaller doses than is 
customary, there would, without doubt, be fewer relapses. Un- 
less contra-indicated by some of the ill effects, it may in all cases 
be given with benefit continuously not only until the disappear- 
ance of the symptoms but also for a long period afterwards. 
During its administration symptoms of constitutional disturbance, 
as ptyalism, and gastric and intestinal derangement, are to be 
watched for ; upon their appearance the dose is to be reduced or 
the treatment discontinued for the time. The period at which 
these symptoms may be looked for varies extremely. In suscep- 
tible cases the system may be affected in a few days ; in another 
case weeks may be required to bring about this condition. 

For early syphilis I am in favor of giving mercury in small 
doses, and of continuing its use for a long period, intermitting its 
administration from time to time. To obtain the best results, it 
should be prescribed according to the following plan, the advan- 
tages of which have been ably set forth by Fournicr.* It should 
be given until all the symptoms have disappeared, and for three 
or four weeks longer, in all probably two months from the com- 
mencement of the treatment, when it is to be interrupted for 
about a month. It is now to be recommenced and continued with 
for another course of two months, when all treatment may be 
stopped for two months. At the expiration of this period of rest, 
a third course is to be undertaken, lasting from six to eight weeks, 
to be followed, as before, by a two months' respite. The whole 
course of treatment should extend over a period of at least two 
years. During the second year it is, in the majority of cases, 
proper to combine iodide of potassium with the mercury. 

Other methods of employing mercury are also recommended 
by eminent syphilologists. Keyesf advocates unhesitatingly the 
practice of giving the remedy unremittingly, in small doses, not 
sufficient to affect the system unfavorably in any way, for a period 
of not less than two years, making use of the iodide of potassium 



* Loc. cit., p. 1080. See a translation by Dr. E. W. Taylor, in the New 
York Med. Jour., vol. xvi. 
f Amer. Jour, of Med. Sci., Jan. 1876, also loc. cit. 



SYPHILODERMA. 543 

when necessary. This plan he calls the " tonic treatment." It is 
best followed by administering the same drug continuously, and 
the protiodide of mercury is to be preferred. One-sixth of a grain 
thrice daily is first given, the dose being increased by one-third 
every three days until slight mercurialization is manifest. The 
"full dose" thus reached is maintained until the activity of exist- 
ing lesions declines, when the "tonic dose," usually about one-third 
of the full dose, is substituted. This should be given continuously. 
Six months, or, better still, a year, of entire immunity from symp- 
toms is desirable before the tonic treatment is stopped. When the 
protiodide of mercury does not agree, blue pill, in half-grain doses, 
alone or with from one-fifth to one-half a grain of the dried sul- 
phate of iron, may be substituted. * I have found this plan of 
treatment valuable, and can heartily endorse its efficacy, but it is 
with difficulty that patients can be induced to continue the reme- 
dies uninterruptedly for so long a period. 

Still another plan is urged; that of giving full doses of the 
mineral in rapid succession until slight salivation is induced, when 
it is withheld for a while. The course is repeated as many times 
as the case may seem to require. The method has been promi- 
nently brought forward by Hunt,f of London. 

The so-called bad or injurious effects of mercury are in all cases 
to be avoided. They comprise ptyalism, tenderness of the gums, 
fetid breath, metallic taste, stomatitis, diarrhoea and griping pains, 
and, at times, depression of spirits, loss of appetite, and general 
malaise. With the manifestation of these symptoms the dose is 
to be at once reduced or the treatment suspended, as the case may 
demand. At the present day, owing to the fact that mercury is 
rarely given in large doses, salivation is not often met with, except 

* For further details upon this plan of treatment, reference may be made to 
Dr. Keyes's treatise, already cited. For valuable information as to the effect 
.of mercury given in tonic doses in increasing the red corpuscular elements 
of the blood and in promoting nutrition, the reader is also referred to two 
papers by Dr. Keyes, one on " The Effect of Small Doses of Mercury, etc." 
(Amer. Jour, of Med. Sci., Jan. 1876), and the other on the " Treatment of 
Syphilis, etc.," read by him before the International Medical Congress at 
Philadelphia, 1876, Section of Dermatology, and contained in the Transactions 
of that body, Phila., 1877. 

f On Syphilitic Eruptions, etc., with Special Keference to the Use and 
Abuse of Mercury. London, 1854. 



544 NEW GROWTHS. 

iu persons peculiarly susceptible to the influence of the drug. 
When slight, it is likely to disappear in a few days on suspending 
the medication. Much relief, however, may be given by the ad- 
ministration of proper remedies. The bowels if constipated should 
be freely opened ; hot baths may be taken, and the action of the 
skin stimulated. If the mouth is sore, nourishment should be 
given in a liquid form. A hot foot-bath with mustard may be taken 
at night, and an opiate, as, for example, Dover's powder, may be 
administered to procure sleep. Half an ounce to an ounce of 
liquor sodae chlorinatae in a pint of water may be used as a gargle. 
In order directly to combat the influence of the mercury no remedy 
is more efficacious than chlorate of potassium, which maybe taken 
internally to the amount of one to two drachms daily, and should 
also be employed in solution as a gargle. Sulphur in small doses 
is highly recommended bj| Piffard * and others. 

Iodide of potassium remains to be referred to. It is a most 
valuable remedy. It finds its chief use in the later eruptions, as, 
for example, those which occur in the second, third, and subsequent 
years. The older the manifestation the more apt is the result to 
be satisfactory. It is prescribed either with mercury or alone. 
Decidedly more lasting effects are to be derived from its employ- 
ment in combination with mercury than when used alone. It is 
administered cither in solution, with wine of iron or with one of 
the palatable syrups, as syrup of orange-peel, ginger, or sarsa pa- 
ri 11a, largely diluted with water. According to Bumstead and 
others, the action of the iodide of potassium is increased by com- 
bination with chloride of ammonium (equal parts). Carbonate of 
ammonium is also said to render it more efficient as well as more 
agreeable. The dose, when used alone, varies from five to thirty 
or forty grains three times daily, the average dose being ten grains. 
When taken for the first time, it is well to begin with smaller doses, 
from two to five grains, gradually increasing the amount. It is 
best administered before meals or about an hour after meals. 

The treatment by iodide of potassium and mercury combined, 
the so-called "mixed treatment," is exceedingly valuable, especially 
in the second and later years of the disease. The two remedies 
are usually mixed in the same prescription. They may also be 

* Diseases of the Skin. New York, 1876. 



SYPHILODERMA. 545 

given separately and alternately at different hours of the day. 
The iodide may also be administered internally in connection with 
mercurial inunction, a plan useful in debilitated subjects, and in 
inveterate cases, where the stomach is apt to become deranged 
under the continued use of mercury. The corrosive chloride and 
the biniodide are the two mercurials ordinarily combined with 
the iodide of potassium. They are prescribed in from one-thirty- 
second to one-eighth of a grain, with from two to five or more 
grains of the iodide of potassium, for each dose, as, for example, 
in the following formula containing the biniodide : 

R Hydrargyri Iodidi Bubri, gr. ii ; 
Potassii Iodidi, giiss ; 
Syrupi Zingiberis, f^iii ; 
Aqiiffi, f§i. 
M. — Sig. One teaspoonful three times daily, after meals, 
with a wineglassful of water. 

The doses of both mercury and iodide of potassium are to be 
increased or diminished to suit the demands of the case. The 
length of time which the iodide of potassium, either alone or with 
mercury, is to be employed, must vary with the case; it may, 
however, be stated that it should be continued for mouths after the 
disappearance of the lesions. The unpleasant effects of iodide of 
potassium consist of iodism, irritation of the mucous membranes, 
salivation, and a peculiar eruption. Iodism is characterized by 
fulness in the head, headache, nervous symptoms, ringing in the 
ears, and general depression. It is only occasionally met with. 
Irritation of the mucous membranes, taking the forms of slight or 
severe coryza, with running at the nose, swelling of the eyelids and 
watering of the eyes, redness of the conjunctivse, and, at times, pain 
in the frontal sinuses, is of much more frequent occurrence. In- 
creased salivary flow may also take place, although it occurs rarely 
in a marked degree. The iodide at times gives rise to eruptions 
upon the skin which assume the form of erythema, papules, pus- 
tules, blebs, and furuncular inflammations. (See Dermatitis 
Medicamentosa.) Iodine, iodide of sodium, and iodide of ammo- 
nium are also at times employed with benefit, but they are inferior 
to the iodide of potassium. 

Local Treatment. — The local treatment of the syphiloder- 
35 



516 NEW GROWTHS. 

mata consists in the judicious employment of baths, lotions, pow- 
ders, or ointments. The erythematous syphiloderm in the majority 
of cases does not require local treatment. Where the lesions per- 
sist about the face, however, an ointment of ammoniated mercury, 
twenty or thirty grains to the ounce, may be used. The mercurial 
vapor bath proves useful in cases where the lesions over the general 
surface are obstinate. The papular manifestations may also be 
much improved by the use of the mercurial vapor bath, or the 
corrosive sublimate bath, in the strength of from one to three 
drachms to thirty gallons of water. Sulphur and alkaline baths 
may also sometimes be employed with advantage. The various 
mercurial ointments are of decided service in removing papules, 
and are often applied to these lesions when they affect the face and 
neck. Ammoniated mercury, a drachm or more to the ounce, and 
ointment of the nitrate of mercury, from one to four drachms to 
the ounce, are the most useful. Oleate of mercury, from five to 
twenty per cent, strength, is even more valuable, and may be em- 
ployed with marked benefit. 

Moist papules in all cases require immediate attention. Strict 
regard to cleanliness is of the first importance; the lesions should 
be washed with water and soap several times in the course of the 
day, and the parts, where the surfaces oppose each other, kept 
separated by linen. \n addition to the cleansing, they may be 
bathed with chlorinated soda solution or a weak lotion of cor- 
rosive sublimate, acid nitrate of mercury, or carbolic acid, after 
which powdered starch, oxide of zinc, or calomel may be dusted 
upon them. They may also be advantageously touched with a 
solution of nitrate of silver. The papulosquamous lesions may 
be treated with the mercurial vapor bath, employed once or twice 
a week. In the localized conditions, as upon the palms and the 
soles, tarry ointments and the various mercurial ointments may 
be applied with benefit. The chronic papulo-squamous palmar 
and plantar lesions, as a rule, require strong applications. The 
various active preparations employed in psoriasis may be advan- 
tageously used. Two drachms of ammoniated mercury to the 
ounce of petroleum ointment will often be found useful. In the 
ulcerative affections the crusts are to be removed by poultices or 
other means, bathed with a lotion of corrosive sublimate or acid 
nitrate of mercury, and the lesions dressed with one or another of 



CARCINOMA. 547 

the mercurial ointments already referred to, or with the "emplas- 
trum de Vigo cum mercurio." The tubercular formations call 
for the same local remedies as the large papules. 

CARCINOMA. 

Under this head are found the several varieties of cancer which 
manifest themselves in connection with the integument, both as 
primary and as secondary affections. Of the primary cancers of 
the skin, by far the commonest form is that to which the term 
epithelial cancer is given ; and it is this which especially concerns 
the dermatologist. Fibrous or hard cancer rarely attacks the skin 
primarily. The melanotic form of the disease, however, is not 
uncommonly encountered as a primary manifestation. The len- 
ticular, tuberous, and melanotic varieties may be briefly described 
as follows : 

The first of these, carcinoma lenticulare, so named by 
Schuh (known also as " scirrhous cancer," " hard cancer," " fibrous 
cancer," and " connective-tissue cancer"), is characterized by pea, 
bean, or larger sized, firm or hard, smooth, glistening, dull pink- 
ish-red or brownish-red, flat or raised papules, tubercles, or nodules. 
They are disseminated, usually occurring over a breast already 
involved, and, while at first discrete, tend to run together, forming 
variously sized tubercular masses or, in some cases, fungoid tumors. 
They almost always appear as a secondary manifestation, and fre- 
quently after extirpation of the primary disease, as of the mamma. 
They are accompanied by hyperemia of a pinkish or violaceous, 
dusky shade, and an indurated or hardened, contracted, smooth, 
glistening state of the integument. The cancerous infiltration 
spreads itself in various directions and widely, so that in extensive 
cases the side of the thorax may appear as if encased in armor, 
constituting "cancer en cuirasse." It pursues usually a slow 
course, accompanied, as a rule, by involvement of the neighbor- 
ing glands, swelling of the limb, softening and ulceration of the 
lesions, lancinating pains, and marasmus, terminating generally 
sooner or later fatally. The disease tends to recur after operation, 
and hence the prognosis is extremely unfavorable. 

The nodular form, designated carcinoma tuberosum, usually 
appears in middle life, but may occur earlier, as a primary or a 



548 NEW GROWTHS. 

secondary manifestation, in the form of circumscribed, flat or raised, 
rounded or ovalish, tubercular or nodular lesions. They are firm 
or hard, are deeply embedded in the skin and the subcutaneous 
connective tissue, and are of a dull-reddish, brownish-red, or 
violaceous color. In size they vary from a pea to a walnut or 
larger. They are multiple, and are generally disseminated or ir- 
regularly grouped, occupying usually the entire surface. Sooner 
or later they soften and break down into ulcers, the disease in 
the course of a few years usually ending fatally. It is a rare form 
of cancer. 

The melanotic variety, termed CARCINOMA MELA NODES or PIG- 
MENTODES, generally begins in the form of multiple, small, pin- 
head, pea, or bean sized, rounded or ovalish, soft or firm papules, 
tubercles, or nodules, of an iron-gray, brownish, bluish-black, or 
blackish color. They are disseminated, and are at first discrete, 
but as they become mure numerous tend to coalesce, forming 
variously-sized, irregularly-shaped, flat or prominent nodules or 
masses. Large tumors may thus be formed, which sooner or later 
soften and ulcerate. Fungoid tumors may also form, which like- 
wise ulcerate, exhibiting a sofi or pultaceous, gangrenous, blackish- 
red, ichorous or bleeding surface. The disease may appear upon 
any |Kirt of the body, but frequently first manifests itself oh the 
hands ami feet. It often has its starting-point in or near a pig- 
mentary mole or a wart. The skin and the eye are the two tissues 
in which it primarily occurs; the internal organs are generally 
involved secondarily. It is usually encountered in early adult or 
middle life, and pursues a rapid and malignant course. 



EPITHELIOMA. 

Sun., Epithelial Cancer ; Cancroid; Carcinoma Epitheliale; Germ., Epi- 
thelialkrebs ; Pr., Epithelioma; Cancroide. 

Symptoms. — Epithelial cancer of the skin manifests itself clin- 
ically in three forms, which are very properly designated as the 
superficial, deep-seated, and papillary varieties. 

Superficial Variety. — This form of the disease, known 
also as the "flat variety," usually makes its appearance as one or 
more grouped, small, yellowish or reddish papules or elevations, 
having their seat in the upper layers of the skin. They may 



EPITHELIOMA. 549 

start from a sebaceous gland, wart, or other growth, or in the form 
of a flat infiltration. Sooner or later, usually in the course of a 
few years, the tubercle, wart, or infiltration, as the case may be, 
shows a disposition to fissure or to excoriate, and to be covered 
with a slight brownish or yellowish crust, under which may be 
observed a scanty, watery, or viscid secretion. The course of the 
disease is commonly slow, years not infrequently elapsing before 
much progress takes place. In time, however, the deposits increase 
in size, or new ones appear, and finally break down into superficial 
ulcers. The ulcer may be no larger than a small split pea when 
first seen, but it inclines to become larger by degrees, and may 
ultimately assume the dimensions of a large coin or even the palm 
of the hand. In shape it is usually roundish ; but it may be 
irregular in outline. Its edges may be sloping or sharply defined, 
flat or raised, but are not usually reddened or infiltrated, although 
they are often indurated. The base of the ulcer is reddish in color ; 
secretes a scanty, viscid, yellowish fluid ; is disposed to bleed ; and 
has an uneven surface, which is apt to be hard. The amount of 
pain present varies, but it is rarely marked until the ulcer has 
assumed considerable size. The further changes which may occur 
vary. At times the ulcer, having assumed a certain size, ceases to 
enlarge; in other cases it extends itself and attacks the deeper 
structures, and passes into the infiltrating, or deep-seated, variety. 
It may continue for years as a local affection, the patient enjoy- 
ing excellent general health. The lymphatic glands are not 
involved. 

The disease which was for a long period designated rodent 
ulcer, and considered as distinct from epithelioma, is a form of 
this variety of epithelial cancer, as has been shown by Warren,* 
a view which is also entertained by Hutchinson f and other recent 
writers. The eyelids are its most frequent seat, and next the sides 
of the nose. When fully developed, it consists of a circumscribed, 
sharply defined, greater or less excavation, with a brownish-red 
or purplish-red, dry or scantily secreting, mammillated surface, 
the ulcer having often a rolled border. It differs chiefly from 



* The Anatomy and Development of Kodent Ulcer. A Boylston Medical 
Prize Essay. By J. Collins Warren, M.D. Boston, 1872. 

f Illustrations of Clinical Surgery, vol. i., Fasc. 1, p. 14. London, 1875. 



550 NEW GROWTHS. 

ordinary epithelioma in its slow course, and in its invading and 
implicating every tissue with which it comes in contact, including 
muscles and bones. It is a disease of the upper portion of the 
face and head, occurring usually above a line drawn across the 
face horizontally on a level with the alte nasi and the lower border 
of the ears. 

Deep-Seated Variety.— This form of the disease, known also 
as the " infiltrating variety," begins by the formation of a roundish, 
often conical, tubercle the size of a split pea, having its seat in 
the skin and subcutaneous connective tissue. It may also start in 
the form of a wart, as in the case of the superficial variety. The 
growth is generally raised, and is deeply seated in the tissues. It 
is reddish or somewhat purplish in color, and is generally sur- 
rounded with an areola. It is firm or hard to the touch, and pre- 
sents signs of extensive infiltration both in the deeper structures 
and around its periphery. Instead of being prominently elevated, 
it may extend itself on all sides in the form of a fiat deposit, but 
slightly raised above the surrounding skin. In a shorter or a 
longer time, usually in the course of month-, according to the 
malignancy of the case, ulceratioD takes place, which begins either 
on the surface or in the interior of the growth. The tumor finally 
breaks up, disintegrates, and an ulcer varying in size, shape, and 
genera] characters results. When of any size, it presents a deep 
excavation in the tissues; is roundish or irregular in shape; and 
has an uneven, reddish, violaceous, or brownish base, with sloping 
walls. It secrete- a pale-yellowish, viscid fluid; bleeds readily 
upon being manipulated; and possesses raised, markedly everted, 
hard, puffed, purplish edges. Infiltration is observed to extend 
it-elf for -nme distance around the cavity, a- shown by the indu- 
ration and the redness of the surface. The destructive process 
usually progresses rapidly, until finally an ulcer the size of a coin 
or larger i> produced. The disease is now painful, the sharp, 
lancinating pains, which are commonly present to a greater or (ess 
extent even in the earlier stage of the disease, becoming severe, 
The lymphatic glands enlarge, and at times break down. The 
patient suffers extremely, and sooner or later succumbs through 
marasmus and exhaustion. The course of this variety of the dis- 
ease varies ; it may be either slow, or, on the other hand, exceed- 
ingly rapid. I well recall the case of a gentleman, sixty-five 



EPITHELIOMA. 55 1 

years of age, who was under my care from the beginning to the 
end, in whom the disease ran its fatal course in one year. 

Papillary Variety. — In the place of an infiltration, as 
described, the lesion may be a papillary growth. Formations 
of this character vary as to size, shape, and outline. They may 
begin as wart-like growths the size of a split pea or finger-nail, 
possessing all the features of a common wart; or they may appear 
as larger, coin or palm sized, raised, lobulated, spongy, markedly 
papillary formations. The appearances vary according to the 
stage of the process. The surface may be either dry or moist. 
At times it is covered with a thin layer of horny, dried, yellowish 
epidermis or scale ; in other cases the epidermis is in a state of 
maceration. Not infrequently the growth gives out a viscid or 
thick secretion, mingled with blood and whitish cheesy or sebaceous 
matter. The granulations may be exuberant, fleshy, and uneven, 
or they may be stunted and flat, inclining to spread out rather 
than to grow in height. Fissures are usually present, which se- 
crete a semi-fluid, offensive product, composed of epithelial and 
sebaceous matter, which with blood forms into brownish, adherent 
crusts. In time the formation, either in places or over its whole 
surface, shows signs of disintegration, an irregularly-shaped ulcer, 
with more or less extensive granulations, ultimately forming, 
which then runs the course of other cancerous ulcers. It may 
begin as a papillary growth, as stated, or, on the other hand, it 
may proceed from a previously existing superficial or deep-seated 
infiltration. 

Epithelioma has its seats of predilection. Its most common 
seat is upon the face. It is encountered upon the lips, more often 
upon the lower lip, where it appears usually in the form either of 
the superficial or the deep-seated variety. It is also of common 
occurrence on the mucous membrane on the inside of the lip, on the 
tongue, and in the mouth. The nose is also frequently attacked, 
the disease very often beginning upon the side of the bridge. The 
cheeks, temples, forehead, eyelids, are also favorite localities. The 
face is much more prone to be invaded by the superficial than by 
the deep-seated variety. The genitalia, especially the penis and 
scrotum in the male, and the labia in the female, are likewise not 
uncommon seats of the disease ; upon the glans penis it is apt to 
show itself as a papillary growth ; upon the scrotum as the super- 



552 NEW GROWTHS. 

ficial form ; upon the labia either as the superficial or the deep- 
seated variety. Other localities are also liable to the disease. The 
lesion is usually single. 

Etiology. — The exciting causes are often obscure. The disease 
is apt to have its starting-point in a locally irritated tissue, as, for 
example, in an excoriation, or about a lip that has been irritated 
by the use of the pipe or through uncleanliness. Warts of all 
kinds are the seat at which it very commonly makes its appear- 
ance. Nsevi, both pigmentary and vascular, are also structures in 
which it may begin. The disease is encountered much more 
frequently in the male than in the female. Thiersch found that 
out of 102 cases collected by him, 80 occurred in men and 22 
in women.* Paget's experience is similar; in 105 cases, affect- 
ing regions common to both sexes, 86 were in males and 19 in 
females.f It rarely shows itself before middle life, commonly 
not before the age of forty or fifty. It may, however, make its 
appearance earlier, and cases arc on record where it occurred in 
childhood. 

Pathology. — The anatomy of the disease varies somewhat with 
the form under consideration, and with the stage of the process. 
According as the growth happens to be superficial, papillary, or 
deep-seated, will there be more or less difference in the anatomical 
arrangement and distribution of the pathological formation. As 
a type of the disease, that which occurs about the lip may be 
taken. If the growth be incised with a knife, the cut surface is 
seen with the naked eye to be of a grayish, yellowish, or pale-red 
color, and to be marked here and there, particularly near the sur- 
face, with numerous minute grayish or yellowish point-, rounded 
accumulations, and irregular bands or streaks, which usually 
occupy a. considerable portion of the structure. These formations 
are the epithelial processes and globes, to be referred to. Upon 
pressure, the cut surface yields a more or less .-canty, watery or 
viscid, yellowish fluid, together with a whitish or yellowish, firm 
or soft, cheesy, more or less granular material. This substance 
may usually be scmeezed out of the growth, when it appears in 
the form of small, rounded, comedo-like plugs. The character 



* Der Epithelialkrebs namentlich der Haut, p. 305. Leipzig, 1865. 
f Lectures on Surgical Pathology, 3d ed., p. 733. 



EPITHELIOMA. 553 

of the product obtained from a section will vary considerably 
with the variety and seat of the disease, as well as with its age : 
thus, it may be dry, friable, and firm, or soft and semi-fluid. The 
amount of vascularity also varies. 

In microscopic structure, epithelioma consists, as Kaposi * suc- 
cinctly states it, of " an inflammatory condition of the tissues of 
the skin, which are infiltrated with lymphoid and proliferating 
cells, and contain numerous dilated bloodvessels, together with an 
effusion of serous lymph within the widened meshes. The tissues 
of the cutis are occupied by a net- work of spaces containing epithe- 
lioid proliferation-cells, nests, or globes, and cylindrical processes, 
formed by the rete mucosum pushing downwards in prolonga- 
tions, like the fingers of a glove. These divide and unite with 
similar neighboring projections to form an epithelial framework." 
The cells may first be referred to. They are of the squamous, or 
pavement, variety, and differ but little from normal epithelium 
as met with upon the skin or mucous membrane of the mouth. 
They present nothing characteristic of epithelioma. They may be . 
arranged in the form either of club-shaped, cylindrical, or conical 
processes, or of rounded nests, or globes (known also as " concen- 
tric globules," " fibrous capsules," " laminated capsules," " onion- 
shaped bodies," " epithelial nests," " pearl globules," " epithelial 
pearls," " epithelial globes"). 

The processes referred to consist of the mucous layer of the 
epidermis, projected into the connective tissue in the form of long, 
narrow, finger-shaped growths. The cells are usually greatly 
crowded, so much so as to constitute solid masses or plugs of 
epithelium. They vary as to size, and as to the depth to which 
they penetrate. At times they are so large as to be seen in sec- 
tions with the naked eye, appearing as streaks and irregular lines 
running from the surface towards the centre of the growth. They 
are not infrequently developed in such numbers as almost to 
obliterate the papillae. In highly developed epitheliomata they 
penetrate in all directions, extend deeply into the connective 
tissue, press upon the surrounding structures, and finally take 
more or less complete possession of the whole skin. Ultimately 
they undergo retrograde metamorphosis, ending either in fatty 

* Path. u. Ther. der Hautkrankheiten. Wien, 1880. 



554 NEW GROWTHS. 

or in keratoid or colloid degeneration. They either disappear by 
absorption, or ulceration results and they are exfoliated from the 
surface. 

The epithelial globes are made up of concentrically arranged 
cells, disposed .like the coats of an onion. In consistence tliey 
may be solid or soft. The cells composing these masses vary ; those 
in the centre are usually small, roundish, and compressed, while 
those on the periphery are elongated, dry, and horny. The globes 
vary in size; not infrequently they are so large as to be readily 
seen with the naked eye. In form they are rounded or ovalish, 
and circumscribed. They are found in the cylindriform proc 
and also in other portions of the growth. They are not, however, 
characteristic of epithelial cancer; they may occur wherever epi- 
thelium is undergoing proliferation and retention, as, for ex- 
ample, in milium and in sebaceous cyst. The amount of stroma 
existing with epithelial cancer varies; it is, however, never a 
marked element, and is seen chiefly in the papillary and deep* 
seated varieties. 

The pathology of so-called rodent ulcer, on which so much atten- 
tion has lately been bestowed, may be referred to in particular. It 
has been carefully studied by Warren,* Butlin,f Thin,| Tilbury 
and T. C. Fox.;; and others. According to Warren, the epithelium 
and papillae are normal in the early stages of the disease. At this 
time -mall tabulated clumps of epithelial cells form just below the 
surface. Mosl frequently the cells lie in solid masses in tube- or 
finger-like prolongations which anastomose more or less freely with 
one another. The epithelium is small and delicate, like that in the 
rete mucosum near the borders of the papillae. Occasionally, how- 
ever, at certain points the epithelium is larger, and forms the centre 
of a concentric arrangement of cells, as in the more characteri-tic 
forms of cancer. Sometimes alveoli of oblong, circular, or tortu- 
ous shape are found tilled with these cells, and in the centre some- 
times an epidermic globe. The cancer cell-masses may at points 
be continuous with the interpapillary epithelium. Warren has 
never been able to discover any connection with the sebaceous or 

* The Anatomy and Development of Rodent Ulcer. Boston, 1872. Also 
Med. Times and Gaz., 1880, vol. i. p. 499. 
flbid., p 23. % Ibid., p. 23. 

a Lond. Path. Soc. Trans.. 1879. 



EPITHELIOMA. 555 

sudoriparous glands. With regard to the point of origin of the 
growth in rodent ulcer, the investigations of T. and T. C. Fox 
go to show that it begins in the external root-sheaths of the hair- 
follicles. 

Concerning the histogenesis, or the formation and development, 
of epithelial cancer, there can be no doubt that it generally takes 
its origin from the normal epithelium of the skin, mucous mem- 
brane or glands. Various researches, however, have established 
the fact that, in addition to the epithelial and endothelial cells, all 
other form-elements, connective-tissue corpuscles, elements of the 
vascular walls, muscle cells, and lymph cells, may go to make up 
the epitheliomatous tissue. Compared with other varieties of carci- 
noma, epithelioma possesses a decidedly less degree of malignancy, 
and this a relatively local one. 

Diagnosis. — Epithelioma may be confounded with syphilitic 
tubercles and ulcerations, acuminated warts, lupus, and the rare 
affection rhinoscleroma. The papule or ulcer of epithelial cancer, 
especially if about the genitalia, may also resemble the chancre; 
but attention to the history, to the duration of the lesion, and to 
other points of diagnostic value, will aid in arriving at a correct 
opinion. The evolution of late syphilitic formations is always 
much more rapid than that of cancerous deposits ; only rarely, in 
malignant cases, does epithelioma run a rapid course. The char- 
acter, moreover, of the ulcerative process due to syphilis is very 
different from that of epithelial cancer. In tubercular syphilis 
two, three, or more points of ulceration are apt to exist ; in cancer 
usually only one. In syphilis the secretion is generally abundant, 
yellowish, and creamy; in cancer it is scanty, streaked with blood, 
viscid, and stringy. The condition of the tissues surrounding the 
ulcer is also different. In the infiltrating variety of cancer there 
is more or less induration ; in syphilis there is none, the deposit 
generally terminating abruptly against the sound skin. In cancer 
there is apt to be pain of a lancinating character ; in syphilis the 
ulcer is usually without pain. 

Inasmuch as many epithelial cancers begin in the form of warts 
or papillomata, it is often difficult to decide whether the lesion is 
a simple wart or of a cancerous nature. The history of the case, 
the mode of advance, the general appearance of the growth, the 
age of the patient, and the course of the disease must determine 



556 NEW GROWTHS. 

its nature. Observation of the case for a time generally enables 
the diagnosis to be established. Epithelioma may be known from 
lupus vulgaris by its usually attacking the middle-aged and the 
old, while lupus commonly first shows itself in the young, often in 
childhood. Epithelioma is almost invariably a single formation ; 
the deposits of lupus are generally multiple. Lupus, moreover, is 
apt to invade several regions of the body at the same time, as, for 
example, the face and hand. When ulceration takes place in lupus, 
or when it assumes an hypertrophic form, the diagnosis becomes 
more difficult, the two diseases in this case often resembling each 
other ; but the peculiar, macular and papular deposits of lupus, 
aggregated into patches, and having their seat usually around the 
ulcer, will serve to distinguish it from epithelial cancer. The dis- 
charge from a cancerous ulcer is, moreover, different from that of 
a lupus ulcer; it is pale, scanty, and viscid, while that of lupus 
is yellowish and puriform. The discharge from epithelioma is 
usually offensive; that from lupus is not so. It will be remem- 
bered, however, as stated in considering lupus, that in rare 
cancer may follow or be combined with lupus. 

Treatment. — The diagnosis once established, the sooner treat- 
ment is instituted the better. Internal remedies are probably of 
no avail. The growth is to be removed, with the knife, caustic, 
actual cautery, or galvano-cautery, with as much of the tissue im- 
mediately about it a- the case in hand may appear to call for. The 
operation to be preferred will depend upon the variety of cancer, 
whether superficial or deep-seated ; the extent to which tin; sur- 
rounding tissues are affected ; and the locality attacked. The 
ultimate result, as regards relapses, will lie found about the same 
with either procedure, provided the operations be performed with 
equal skill. Superficial epitheltomata are, in the majority of cases, 
best removed with caustic. Among the various remedies, caustic 
potash, in stick form or in solution, occupies a high position. It 
causes much less pain than other powerful caustics; which, more- 
over, does not continue after the cauterization, and by means of 
acids may be at once relieved. The growth should be thoroughly 
cauterized, no part of it being permitted to remain undisturbed. 
This remark applies to all forms of operation, whether with caustic 
or other means. In all cases it is advisable to carry the caustic 
into the border of the sound tissues. As the operation is being 



EPITHELIOMA. 557 

performed, the operator must determine the extent of the disease 
and the amount of tissue to be acted upon. The readiness with 
which the morbid tissue gives way and is destroyed under the 
caustic, and the resistance experienced when in contact with normal 
structures, will enable the surgeon to know when to desist from 
further cauterization. There is usually no hemorrhage. After 
the operation the parts are to be bathed with dilute acetic acid, and 
subsequently dressed with diachylon ointment or olive oil. The 
dressing may be changed twice daily, and the wound washed with 
soap and water. In the course of ten days or two weeks the eschar 
will have detached itself, showing usually a healthy granulating 
wound, which, in cases favorably disposed, will heal completely, 
leaving not infrequently an insignificant scar. On the other hand, 
in cases where the disease is of a malignant type, the wound re- 
pairs itself sometimes in apparently the usual healthy manner for 
the first few weeks, after which the reparative process arrives at a 
stand, and the ulcer soon breaks down into its former state. This 
is apt to be the course of the deep-seated variety. Potassa cum 
calce, in stick or in powder form, made into a paste, is also a valu- 
able preparation. It is at times to be preferred to pure potassa. 

Other caustics are used for the same purpose. The chloride of 
zinc, either in the form of a paste, with flour, or in stick form, 
enjoys a reputation, especially for the superficial variety. It is 
effective, but intensely painful, the pain often remaining uncon- 
trollable for several days. I have known it to be so severe and 
so long continued as to prostrate the patient. It is, moreover, 
doubtful whether it possesses the advantages over other caustics 
which have been claimed for it. Arsenic, in the form of a paste, 
with powdered acacia, equal parts, may be used with much suc- 
cess in many cases of the superficial variety. It is effectual, and 
can be recommended. A useful powder, employed by Esmarch, 
consisting of arsenious acid, one part ; sulphate of morphia, one 
part ; calomel, eight parts ; and powdered acacia, forty-eight 
parts, may also be mentioned. Pyrogallic acid, in the form of an 
ointment, one or two drachms to the ounce, as recommended by 
Kaposi, Jarisch, and others, I have also found especially valuable. 
I have obtained excellent results from its use where other remedies 
have failed, and can heartily endorse its value. It should be 
spread upon muslin and applied for from two to six days con- 



558 NEW GKOWTHS. 

stantly. It is to be particularly recommended above other caustic 
remedies on account of its painlessness. Nitrate of silver may be 
used for destroying the early formations and deposits which are 
apt to occur about the margin of superficial ulcers. Whatever 
remedy be employed, it should be thoroughly applied ; the more 
radical the operation, the less likelihood of a relapse. 

On the other hand, there are cases in which it is preferable 
to use the knife instead of caustic. The extent of the disease, 
the locality invaded, the previous failure of caustics to arrest the 
process, and other circumstances, frequently render extirpation 
with the knife the best mode of procedure. When the disease is 
of the deep-seated or infiltrating variety, the best hope of a cure 
is doubtless in the Tagliacozzian operation. The lesion is first 
completely excised, and is replaced by a flap of sound skin, taken, 
if possible, from a remote region, as the forearm or hand, with 
the pedicle attached. Garretson speaks in praise of the opera- 
tion,* and I have every reason to believe that his success, with a 
number of such cases, has been remarkable. It is of special value 
in cases of recurrenl disease. The galvano-cautery has also been 
employed with marked success, and is an effective remedy.f It 
is particularly adapted t«» case- where the growth occupic- regions 
which could only with difficulty be treated with caustic or the 
knife, as about the inner canllius of the eye. Hebra, Kaposi, 
Auspitz, and others speak well of the scraping spoon, or curette, 
in the. treatment of superficial formations, used a- in lupus vul- 
garis, already described. Except in superficial cases, its employ- 
ment should always be supplemented by one of the can-tie-.. 

Prognosis. — This i.^ always more or less unfavorable, varying 
considerably, however, with the case. The age of the patient; 
the duration of the disease; its course; its locality; and whether 
single or multiple, must be taken into account. The variety of 
the disease, whether superficial or deep-seated; the amount of sur- 
rounding infiltration; and the presence or absence of glandular 
involvement, must also be considered. The superficial variety 
may increase slowly in size for years without giving rise to serious 



* System of Oral Surgerv, Phila., 1873; also Phila. 3Ied. Times, Sept. 25. 
1880. 
f See a paper, with cases, by Bryant, Lancet, April i, 1874. 



SARCOMA. 559 

disease, as, for example, in the case of so-called rodent ulcer ; on 
the other hand, it may extend rapidly until an ulcer of consider- 
able size has formed ; or it may pass into the deep-seated variety, 
when the prognosis becomes at once more grave. The deep-seated 
variety is always a serious disease. Its course, however, varies 
greatly. At one time it runs a rapid pace, terminating fatally in 
one or two years; in other cases it extends through a much longer 
period. In either variety relapses frequently take place. The 
patient should be warned concerning the liability of the disease 
to recur. 

SARCOMA. 

Sarcoma of the skin consists of shot, pea, hazel-nut or larger 
sized, variously shaped, discrete, non-pigmented or pigmented 
tubercles or tumors.* Non-pigmented tumors, occurring as single 
or multiple growths upon the various regions, represent perhaps 
the commonest manifestation of the disease. They are smooth, 
firm, and elastic, are not markedly painful upon pressure, and 
are reddish, violaceous, or brownish in color. Such tumors are 
of more frequent occurrence than is generally supposed. Thus, 
Billroth f refers to fifty-nine cases of sarcoma of the skin, com-, 
prising the several varieties of the disease, occurring upon various 
regions of the body. S. W. Gross J also records cases and other 
interesting information concerning the disease as it is encountered 
upon the breast. Sarcoma may sometimes resemble keloid, as in 
a case reported by Satterthwaite.§ 

The multiple pigmented sarcoma (melano-sarcoma), according 
to Kaposi, of which he mentions five cases,|| generally first appears 
on the soles and backs of the feet, and later on the hands, attended 
by a diffuse thickening of the skin. It may also begin on other 
regions, as Piffard has pointed out.^[ The lesions often manifest 

* For further information on the disease, see Wigglesworth (Arch, of Derm., 
vol. ii. No. 2), Kaposi (Diseases of the, Skin, vol. iv.), and Kobner (Archiv 
fur Derm, und Syph., Heft 3, 1869). 

f Chirurgische Klinik, Wien, 1871-76. 

% Treatise on Tumors of the Mammary Gland. New York, 1880. 

I New York Med. Kec, 1876, p. 610. 

|| In a later work (Path. u. Ther. der Hautkrankheiten, Wien, 1880) he 
speaks of having since encountered five additional cases, occurring in men. 

\ Mat. Med. and Ther. of the Skin. New York, 1881. 



560 NEW GROWTHS. 

a ready disposition to bleed. They are brownish, bluish, or black- 
ish in color. 

Sarcoma may be mistaken for cancer, the papular syphilodcrm, 
gumma, lupus, and lepra. It may occur at any age after puberty, 
but is commoner towards middle life. It is malignant in character, 
often proving fatal in the course of a few years. The growth 
may be either a small or large round-celled or a spindle-celled 
sarcoma. Kaposi's cases showed the structure to consist of clus- 
ters of small round cells in the corium, slight hemorrhages into 
the corium and papillary layer, and an abundance of pigment. 
In ^Wiggles worth's case the disease was found to be seated mainly 
in the cutis, and to consist of large round cells with single gran- 
ular nuclei, relatively uniform in size, and considerably larger 
than white blood-corpuscles. They were embedded in a reticu- 
lated, delicately fibrous stroma, the meshes of which enclosed, as 
a rule, single cells. 

The rare disease described by Gebcr* and myself, t under the 
name INFLAMMATORY fungoid NEOPLASM, may here be referred 
to. Hebra first encountered the disease in 1872, a short ac- 
count of it appearing in the annual report for 1873 of the Vienna 
General Hospital. In L875 the case waa republished by Hans 
Hebra, while more recently Geber has made it the subject of 
an article. Jn 1874 Hebra encountered a second case. A case 
was also presented by Piffard to the New York Dermatological 
Society, the notes of which, however, were not recorded.^ 

The lesion8 are of several distinct kinds, the more important 
consisting of flat or slightly raised patches, and of prominent fun- 
goid tumors. The flat patches vary in size from a -mall coin to 
the palm of the hand, are rounded or ovalish, and are either on a 
level with the surrounding skin or raised. They may be super- 
ficial or deep-seated, smooth, scaly, or crusted, and of a pale-pink- 
ish or deep-reddish color. With involution they generally assume 
a mottled or streaked purplish, yellowish, or salmon color. The 
tumors are round, rounded, or ovalish, tubercular or fungoid in 

*Deutsches Archiv fur Klin. Med., Bd. xxi., Heft 2 u. 3, Miirz, 1878. 
Leipzig. (With a chromo-lithograph.) 

f Arch, of Derm., Jan. 1879, and Jan. 1880. (With two portraits.) 
1 Trans. Amer. Derm. Assoc, 1878. 



SARCOMA. 561 

character, varying in size from a pea to an egg, and of a pale-red, 
deep raspberry-red, or violaceous color. They are soft, firm, or 
solid, and when fully developed are more or less distinctly furrowed 
and lobulated and depressed in the centre. They have a smooth 
and glossy surface, or they are excoriated and ooze a thin, serous, 
bloody discharge, or a puriform fluid which dries into brownish 
crusts. They may appear suddenly, within a few hours or a day, 
or gradually, in the course of weeks or months. Having attained 
a certain size, they tend to soften, diminish in size, and either 
undergo spontaneous involution or ulcerate.* The subjective 
symptoms consist of itching and burning, but are variable. All 
regions are liable to be invaded, and without symmetry. The 
course of the disease is variable, but the process tends sooner or 
later to terminate fatally. The individual lesions generally 
pursue a capricious course, and in marked cases may usually be 
observed in all stages of evolution and involution upon the same 
subject. 

Under the microscope the disease is seen to consist of a profuse, 
closely packed, small round-cell infiltration, completely occupying 
the corium and the subcutaneous tissues. The cells are small, 
variable as to size and shape, compact and shining, and finely or 
coarsely granular. The larger ones show nuclei. They are vari- 
ously arranged, in the form mainly of dense aggregations, or in 
strings or columns, the latter following the course of the fibrous 
connective tissue. Heitzmannf regards the disease as sarcoma, a 
view which is also held by Kaposi.J The case reported by me 
exhibited in its early history (during the first year) marked in- 
flammatory symptoms, which led me to give provisionally the 
name inflammatory fungoid neoplasm to the disease, expressive 
of its chief characters. The name was likewise adopted at about 
the same time by Geber. Later in its course, however, the micro- 
scope showed the process to be rather of a sarcomatous and fibro- 
sarcomatous nature. The disease is to be distinguished from the 

* See interesting articles on the spontaneous disappearance of tumors (in- 
cluding the disease under consideration) by Augagneur (Lyon Medical, Nos. 
24, 25, 26, t. xxxvii., 1881), and Dwight (Bost. Med. and Surg. Jour., Dec. 
9, 1880). 

f Arch, of Derm., Jan. 1879. 

X Path. u. Ther. der Hautkrankheiten. Wien, 1880. 



562 NEW GROWTHS. 

fungoid forms of lymphadenorna, cancer, and syphilis, and from 
lupus vulgaris, lepra, and framboesia. The disease described by 
Van Harlingen* as a case of "ulcerative scrofuloderm" (which 
was also under my observation) may, I think, be regarded as 
probably another variety of the same disease, the latter stages of 
the process having marked symptoms in common with the case 
of inflammatory fungoid neoplasm described by me, including its 
fatal termination. 

The so-called " fungoid diseases of the skin," instances of which 
have been reported from time to time, except when manifestly 
varieties of cancer or of the other diseases enumerated, are for 
the most part obscure in their nature. Kobnerf collected five 
rare cases of the kind, which were observed in the Hopital St. 
Louis, Paris, and designated them provisionally " multiple, fun- 
goid, papillomatous tumors of the skin." Two of the cases were 
observed by Hardy, and two by Bazin, the latter reporting one of 
them in his treatise on diseases of the skin with the name " mycosis 
fongoidc." The fifth case had been previously recorded by Alibert. 
Several, if not all, of these cases possess many symptoms in com- 
mon with the disease under consideration, as described by Geber 
and myself, and may be regarded as probably of the same 
nature. Tilbury Fox J likewise described a rare form of fungoid 
disease of the skin with the name "fibroma fungoides," differing 
from ordinary fibroma in its vascularity, rapid growth, and ten- 
dency to ulcerate, which doubtless possessed a similar pathology. 
There remains, still to be referred to the so-called "lymphad&iie 
cutanee," or "mycosis fongoi'de," of Gillot§ and Demange,|| the 
nature of which is not clear, but which presents many features iu 
common with the disease under discussion. 

Eeference may here be made to a rare case of disease reported 



* Arch, of Derm., April, 1879. 

f Klinische und experimentelle Mittheilungen aus der Derraatologie und 
Syphilidologie, p. 37. Erlangen, 18G4. 

X Skin Diseases, 2d Amer. ed. New York, 1873. 

I Etude sur une Affection de la Peau decrite sous le nom de Mycosis fon- 
goide (Lymphadenie cutanee). Paris, 1869. 

|| Du Mycosis fongoide ou Lymphadenie cutanee. Annales de Derm, et 
de Syph., No. 2, 1873-74. 



N^EVUS VASCULOSIS. 563 

by Hardaway,* of St. Louis, consisting of "multiple tumors of 
the skin accompanied by intense pruritus," the nature of which 
is not plain. The patient was a middle-aged lady in good general 
health, whose hands and feet, including the palms and soles, fore- 
arms, arms, and legs, were the seat of numerous, symmetrically 
distributed tubercles and tumors, varying in size from a pea to a 
hickory-nut, covered with a thick, scaly epidermis and having a 
resistant horny feel. In places they had coalesced, forming nodular 
patches, while here and there existed variously sized and shaped 
thick patches or plates of disease involving the entire thickness 
of the skin. The lesions were accompanied by intense itching. 
The disease was of twenty years' duration, and began in the form 
of blebs, which were soon followed by the tubercles and tumors. 
Occasionally the tumors ulcerated, but afterwards healed up. The 
growths when excised recurred, and in the same form as the origi- 
nal lesion. Microscopical examination by Heitzmann showed the 
disease to be due to a chronic inflammatory process having its 
seat mainly in the upper layers of the derma. 

MVUS VASCULOSIS. 

Syn., Nsevus Vascularis; Nsevus Sanguineus ; Germ., Gefassmal. 

Symptoms. — Vascular nsevi are congenital formations, composed 
chiefly of bloodvessels, which have their seat in the skin and sub- 
cutaneous tissues. Their clinical characters vary. They may be 
prominent, turgescent, erectile, or even pulsating, tumor-like, cir- 
cumscribed growths, with usually an uneven or rugous surface 
(angioma cavernosum, n^evus TUBEftosus) ; or they occur as 
flat, non-elevated, well or imperfectly defined, distinct or faint, 
smooth patches (njevtjs flammetjs, njevus simplex, angioma 
simplex). The latter form is also known as " port wine mark" 
or " claret stain ;" and in German as " feuermal," and in French 
as "tache de feu." In form nsevi are roundish or irregularly 
shaped. They are bright or dark reddish, violaceous, or bluish 
in color, varying considerably in shade. They may be either 
small, pea or bean sized, or much larger, sometimes so extensive 
as to cover palm or hand sized areas. They are seldom multiple. 

* Arch, of Derm., April, 1880. 



564 NEW GROWTHS. 

They are encountered upon all parts of the surface, but are in the 
majority of cases met with about the head, and especially the face, 
and in particular the lips. They vary in their course; very often, 
having attained a certain size early in life, they remain stationary, 
while at times they retrograde to a variable extent. Sometimes, 
on the other hand, especially in the case of the larger erectile for- 
mations, they increase in size. The more vascular they are, the 
more likelihood is there of their becoming larger. Ordinarily 
they remain as permanent deformities. Sometimes, in the case 
of the simple diffuse, flat growths, they entirely disappear, as a 
rule, early in life. They are all characterized by becoming paler 
under pressure, the more prominent growths being markedly coni- 
pressible. 

Pathology. — The causes which give rise to these formations are 
obscure. In structure they are simple or complex, consisting of 
dilated and hypertrophied bloodvessels and capillaries, both arteries 
and veins, which have their seat in the corium and subcutaneous 
tissues. The vessels are to be considered as an abnormal growth, 
being present in unusual size, number, and arrangement. The 
flat or simple angioma (naevus flammeus, or port wine mark) con- 
sists of a diffuse new growth of bloodvessels, chiefly of capillaries, 
in the corium, and especially in the upper layer-. In the so-called 
"lobular angioma," as seen on the face, especially about the lip, 
the bloodvessels are convoluted, the lobules being separated by 
more or less connective tissue. In the cavernous form a varying 
amount of connective tissue likewise exists. Other structures 
common to the normal skin, as hairs and glands, are also usually 
present. Sometimes they arise from the subcutaneous tissui 
pecially from the adipose layer, constituting "angioma lipoma- 
todes." At times they are somewhat verrucous in character, while 
occasionally they are pigmented. 

Treatment. — The treatment to be recommended for the removal 
of naevi, when this is called for, will depend upon the region in- 
volved, and the size, form, and general character of the formation. 
Various means have been suggested: those which have been at- 
tended with most success are the following. Pin-head sized nsevi 
may be treated by puncture with a red-hot needle, or a needle 
charged with nitric acid ; or with a needle and from six to twelve 
cells of the galvanic battery, as in telangiectasis. When the 



N^EVUS VASCULOSIS. 565 

growth is the size of a split pea and circumscribed, it may be 
treated by caustic applications. Sodium ethylate, first brought 
into notice by B. W. Richardson, is an efficient and valuable caus- 
tic in the more superficial forms of nsevi.* It is made by adding 
the metal sodium to absolute alcohol, and is best applied by means 
of a glass rod. Although the pain accompanying the application 
is not severe, yet it may be lessened by the addition of an alcoholic 
solution of opium to the sodium ethylate. To insure good result, 
it is necessary to employ pure ethylate of sodium ; if the prepara- 
tion be made with alcohol containing water, the caustic agent set 
free is ordinary caustic soda, and not sodium in a nascent state. 
Neither poultice nor water-dressing should subsequently be applied, 
the result of contact with hydrous substances being to give a sup- 
purating character to the wound. The crust should always be 
permitted to loosen itself before removal. Blighf recommends 
painting the nsevus with liquor plumbi subacetatis, applied once 
daily. Usually in about four months, in some cases longer, the 
lesion becomes dotted over with white spots, which gradually 
coalesce until the nsevus has disappeared. Caustic potash, ap- 
plied in solution, the strength varying according to the amount 
of surface to be attacked, may also be used with good result. 
The smaller the growth, the stronger may the solution be made. 
From one to four drachms to the ounce of water may be used, 
one or two applications sometimes sufficing. Nitric acid may also 
be employed^ especially in the case of flat nsevi, painting the sur- 
face sufficiently to cause slight superficial cauterization. If the 
growth be of any size, a portion only should be attacked at one 
operation. 

Neumann speaks well of an ointment composed of adhesive 
plaster, one drachm, tartar emetic, nine grains, for small, finger- 
nail sized, raised or flat, circumscribed nsevi, especially of the scalp. 
Pustulation and free suppuration take place, followed by a flat, 
thin, soft scar. The application causes but little pain. Success 
sometimes follows the use of collodion and corrosive sublimate, in 
the strength of eight grains to the fluidrachm. Injections with 
the sesquichloride of iron, cantharidine, and other like substances, 



* Lancet, 1878, vol. ii. p. 654; also 1881, vol. i. p. 168. 
f Brit. Med. Jour., Sept. 25, 1880. 



566 NEW GKOWTHS. 

as formerly practised, are not to be recommended, being apt to 
cause extensive sloughing, and, at times, hemorrhage. 

Linear scarification has been recommended by Squire for port 
wine mark.* It is accomplished by scratching or cutting the 
naevus in numerous minute, superficial, parallel lines oblique to 
the surface, one-sixteenth of an inch apart, and following these 
with a series of others at right angles and also slanting, so that 
all the minute bloodvessels, both vertical and horizontal, may be 
cut through. The skin is first frozen with ether spray and press- 
ure exercised before thawing and continued ten or fifteen minutes. 
Squire claims that this process is painless and bloodless, and that 
it leaves no scar. Malcolm Morris and McCall Anderson, how- 
ever, assert that after many trials the method has in their hands 
proved entirely unsuccessful^ 

Punctate scarification for the same form of naevus is recom- 
mended by Sher\vell,J by means of an instrument composed of a 
number of fine needles arranged in a bundle with the points some- 
what less than one-sixteenth of an inch apart. They are thrust 
suddenly, by the action of a spring, to a given depth into the nsevns. 
These needles may be charged with a saturated or a fifty per cent, 
solution of carbolic acid, or with a twenty-five or forty per cent. 
solution of chromic acid. Pressure soon causes the slight bleed- 
ing and oozing to cease, after -which the part is washed off with 
alcohol and a thick layer of two or three coats of collodion is ap- 
plied. Like Squire's linear scarification operation, this procedure 
has not always been successful in other hands than those of its 
originator. 

Vaccination upon nsevi is at times followed by very satisfactory 
results, especially in the case of small formations, and is well 
spoken of as a means of treatment by numerous observers. Ra- 
gaine§ reports seven cases of erectile nsevi cured by this means. 
Paul || also reports favorable results with the same class of njevi, 
and advises abundance of vaccine matter, which should be spread 
over the whole surface. According to Ragaine, the operation may 

* Brit. Med. Jour., vol. ii., 1879. 

f Arch, of Derm., Oct. 1879 

X Ibid., 1879, vol. v. p. 354. 

\ Jahresbericht der Gesammt. Med., 1874. 

|| Abstract in Lond. Med. Rec, Aug. 15, 1881. 



3S\EVUS VASCULOSIS. 567 

be performed about the circumference of the tumors or directly 
upon their surface. It is important that the points of insertion 
should be made as far apart as about a half-inch. The best instru- 
ment for the purpose is an insect-needle, the hemorrhage following 
the use of a lancet being apt to wash away the vaccine matter. 
To prevent such an accident, the needle may be permitted to re- 
main in the puncture for a few moments. The size of the tumor 
is said never to be a counterindication to the employment of this 
method. 

The treatment by the introduction of the galvanic current con- 
stitutes the most generally useful method. Numerous instances 
of its successful employment are upon record.* The advantages 
claimed for it over other methods of treatment may be briefly 
stated as follows : the safety of the operation ; the absence of 
hemorrhage ; the cessation of pain after operation ; the absence 
of scar in small naevi ; and, finally, the simplicity, rapidity, and 
effectiveness of the operation. From six to twelve cells are 
usually sufficient. One or more platinum needles, according to 
the size of the nsevus, are connected with the negative pole, and 
a single needle, or, when the growth is large, a charcoal point, 
to the positive pole. After the needle has been in the tumor a 
short time, decomposition begins, gas pours out by the sides of 
the needle, a clot is formed, and the tumor turns bluish-white. 
Sloughing should, and can by proper care, be avoided. Suppu- 
ration, even, ought not to occur. 

The galvano-cautery is likewise a valuable means of treatment, 
and is highly recommended by Dawson and Allen, f by means of 
the needle, knife, or platinum strip. For superficial nsevi all that 
is required is such a degree of heat as will radiate into the deeper 
tissues from the surface. In treating the subcutaneous formations 
a white heat is necessary, in order that the knife or needle shall 
retain sufficient heat to be of service when it has reached the 
deeper structures. According to Dawson, the galvano-cautery 
produces a clot which becomes rapidly organized and a shrinking 



* See papers by Carter, Lancet, Jan. 18, 1873 ; Penhall, Lancet, April 11, 
1874; Beard, Phila. Med. Times, Sept. 5, 1874; Knott, Lancet, March 20, 
1875; Duncan, Edin. Med. Jour., Feb. 1876. 

f New York Med. Kec, 1876, vol. xi. pp. 11, 12. 



568 NEW GEOWTHS. 

in the calibre of the vessels which remains permanent, effected 
without destruction of tissues. Iu superficial ntevi of moderate 
size a single thorough application sometimes produces a cure. 
Where they are large, a portion only should be operated upon 
at a time. 

Where the tumors are prominent or pedunculated, the ligature 
may often be employed with good result, although a scar is apt 
to remain in cases where the growth is of any size. Compression 
may also be tried. 



TELANGIECTASIS. 

Telangiectases are vascular cutaneous formations which make 
their appearance during the life of the individual. They are, 
therefore, acquired growths, in contradistinction to those which 
are congenital, and which are called mevi. They occur either in 
the form of more or less circumscribed formations or as tortuous 
lines, visible to the naked eye as a net-work of enlarged capilla- 
ries. The circumscribed growths vary in size from a pin-head to 
a pea. They are on a level with the surrounding skin or are 
raised, sometimes to the height of a split pea. In shape they are 
roundish, ovalish, or irregular. In color they vary from bright to 
dark or violaceous red. They show themselves singly or in num- 
bers; one, two, or three may not infrequently be observed here 
and there over the surface. They may develop upon any region, 
but are most frequently encountered upon the face and thorax. 
The lines appear in the form of an ill-defined patch or as a col- 
lection of distended capillaries, more or less distinct in outline, 
ramifying over the surface in a tortuous manner. They are met 
with chiefly upon the face and chest. As a rule, telangiectases do 
not manifest themselves until adult or middle age. They are un- 
attended by subjective symptoms. Their course is slow, enlarging 
usually only through a period of years; but fhey rarely attain any 
size. They generally remain as permanent growths ; occasionally 
they disappear spontaneously. 

Rosacea.— By this term is designated a variety of telangiec- 
tasis, characterized by a diffused, more or less general dilatation of 
the cutaneous capillaries, usually of the face. The vessels are en- 
larged, and give the skin a reddish appearance marked with faint 



LYMPHANGIOMA. 569 

or distinct lines which are generally irregular or tortuous in their 
course. The condition may be localized, as is ordinarily the case, 
as, for example, upon the nose, or generalized, occurring over the 
greater portion of the face. Its common seat is the nose, but it 
also manifests itself frequently upon the cheeks and chin. The 
forehead may also be attacked, either alone or in connection with 
other parts of the face. 

Rosacea is very often complicated with acne, giving rise to acne 
rosacea ; but it may occur as the sole disease, without disturbance 
of the sebaceous glands. It may also appear upon the nose in 
connection with seborrhcea in chlorotic and anaemic individuals. 
In simple rosacea the skin is usually smooth ; but in aggravated 
cases it may be uneven, owing to the extreme distention and ele- 
vation of the superficial vessels. When seborrhoea is present, the 
part presents a shining, more or less greasy appearance. Upon 
pressure the redness disappears for the moment, but quickly re- 
turns. The part is often warmer than normal; in seborrheic 
cases, however, it may be below the normal temperature. The 
color may be either bright red or violaceous, depending upon the 
duration of the disease, the age of the patient, and the cause. In 
rosacea complicated with acne the nose in men usually becomes 
enlarged, and the whole cutaneous tissue hypertrophied. (See 
Acne Rosacea.) The treatment of telangiectasis is that of nsevus 
vasculosus; but I desire to direct attention especially to the value 
of electrolysis, as recommended by Hardaway,* the method of 
treatment being the same as that described in connection with the 
removal pf superfluous hairs, to which the reader is referred. 

LYMPHANGIOMA. 

This very rare disease was first described by Hebra and Kaposi,f 
with the name lymphangioma tuberosum multiplex. A case 
is also reported by Pospelow,| identical in its chief features with 

* Arch, of Derm., Oct. 1879. 

f Loc. cit., vol. iii. p. 387. A portrait of the case reported by Kaposi occurs 
in Hebra's Atlas of Skin Diseases, Lieferung X., Tafel 6. See also Biesiadecki, 
Untersuchungen aus dem Path.-Anat. Institute in Krakau, p. 11. Wien, 
1872. 

X Viertelj. fur Derm, urid Syph,, Heft 4, 1879. 



570 NEW GROWTHS. 

that of Kaposi. It is characterized by numerous, scattered, pea 
or bean sized, ovalish or rounded, brownish-red, glistening, some- 
what transparent, smooth, flat, slightly elevated tubercles, occur- 
ring for the most part about the trunk. They become pale on 
pressure ; are firm and elastic to the touch ; and are embedded in 
the corium, but are not sharply defined. As characteristic of the 
disease, Pospelow calls especial attention to the transparency of the 
lesions, and the readiness with which they can be made to sink 
below the level of the surrounding skin. They are slightly pain- 
ful on pressure. In appearance the disease resembles the large 
flat papular syphiloderm. Microscopical examination of excised 
lesions shows the whole corium to be perforated by variously sized 
canals, which appear as rounded or ovalish apertures, and which 
are immensely developed lymphatic vessels and lymph spaces. 
The growth consists almost entirely of this structure, and has its 
chief seat in the corium. In both cases reported it manifested 
itself in childhood, or was congenital. The general health remains 
good. The course of the disease is extremely slow, it evincing no 
disposition to malignancy. 

Van Harlingen* gives a case illustrating another form of the 
disease, occurring in a woman thirty years of age, characterized 
by a large number of tumors of various sizes and shapes distrib- 
uted over the whole body, together with numerous telangiectases 
and irregular brownish patches of pigmented skin. The tumors 
in some instances resembled flabby mo'lluscum fibrosum growths, 
while in other cases they were smooth lilac or bluish elevations 
from pin-head to hazel-nut size, and so compressible under the 
finger as to feel like bladders filled with air. On excision they 
were found to consist of a pearly, gelatine-like, semi-transparent 
mass. Microscopic examination showed the structure to be com- 
posed of fibrous and granulation-cell tissue, with numerous irreg- 
ular spaces, — sections of dilated lymphatic vessels.f 

* Trans. Amer. Derm. Assoc, 1881. 

f In this connection reference may be made to several cases of disease char- 
acterized by cutaneous cysts which have been reported from time to time, the 
nature of which is not clear. See Jamieson (Edin. Med. Jour., Sept. 1873), 
Tilbury Fox (Trans. Lond. Path. Soc, 1879, "a case of lymphangiectodes"), 
and Hutchinson (Lancet, 1879, vol. ii. p. 912). In Hutchinson's cases there 
were groups of wart-like patches, which on close examination were found to 



NEUROMA. 571 



NEUROMA. 



"With the name neuroma of the skin I would describe a disease 
characterized by the presence of variously sized and shaped neu- 
romatous growths having their seat primarily in the true skin. 
The affection is exceedingly rare, there being, to my knowledge, 
but two cases upon record, the first reported by myself,* the 
other subsequently by Kosinski.f I shall present an abstract of 
them. 

Case I.— The patient was a man, aged seventy, who had been 
under my observation for six years.J The disease began at the 
age of sixty, in the form of small, rounded tubercles, upon the 
shoulder, attended with itching but not pain. For a period of 
four years they continued to appear in numbers, so that by the 
end of this time the arm and shoulder were well studded with 
them. During the subsequent six years they manifested them- 
selves at longer intervals, and their development was slower, 
although new ones still made their appearance from time to time, 
the original tubercles scarcely increasing in size. 

The disease was characterized by numerous small, split-pea 
sized, firm, flattened tubercles, occupying the left scapular region, 
shoulder, and outer surface of the arm as far down as the elbow. 
Over the shoulder and arm they were closely packed together, the 
surface presenting a mass of firm, tuberculated tissue. They were 
immovable, and firmly incorporated with the skin, and extended 
into the subcutaneous connective tissue. They were irregularly 
disseminated, and occupied no nerve tract. About the scapular 
region, and down the arm near the elbow, they were more scattered 
and discrete, the skin between them being normal. They were 
pinkish or purplish-pink, the more recent, isolated formations 
being a pale rose or the color of normal skin. The color of the 
diseased surface, as a whole, varied according to the position of 

be composed of congeries of minute cysts with albuminous and corpuscular 
contents. The term "lymphatic warts" was suggested. 

* Case of Painful Neuroma of the Skin. Araer. Jour, of Med. Sci., Oct. 
1873, and Oct. 1881. 

f Neuroma Multiplex. Centralblatt fur Chirurgie, No. 16, 1874. 

$ The notes describe the disease as it existed before the operation (in Octo- 
ber, 1874). 



572 NEW GROWTHS. 

the limb and the presence or absence of pain. The surface was 
warmer than the adjacent healthy skin, and during an attack 
of pain became hot and violaceous in color. Fine, laminated, 
yellowish, glistening scales were scantily produced and shed 
from the tubercles, giving the affected part a dry, somewhat scaly 
aspect. 

Paroxysmal pain constituted the distressing feature. This did 
not manifest itself till three years after the tubercles had begun to 
form. It was excruciatingly violent, shooting down the arm as 
far as the knuckles, across the chest, and up the side of the neck 
and head, the paroxysms usually lasting an hour or longer. The 
exciting causes were movement of the affected part, exposure to 
cold air, and mental worry or excitement. Any decided change 
to bad weather was accompanied by an attack, and there was 
greater immunity from pain in summer than in winter or during 
a rainy or snowy season. The nutrition of the arm was not im- 
paired. The general health was good, and no cause could be 
assigned for the disease. Microscopic examination of excised 
tubercles revealed the growth to be made up of a firm connec- 
tive tissue containing non-medullated nerve fibres, running up as 
high as the papillary layer of the oorium, constituting true neu- 
roma amylinicum of the skin.* None of the various methods 
of treatment employed from time to time having proved of ben- 
efit, exsection of a portion (one inch) of the brachial plexus 
of nerves was performed by Dr. F. F. Maury. The operation 
was followed by the usual symptoms of atrophy after nerve sec- 
tion, by marked diminution of pain, and by some decrease in 
the size of the growths. The relief, however, was only tem- 
porary, f 

Case II. — Kosinski's case was a man, aged thirty. The disease 
made its appearance in his sixteenth year. The tubercles were at 
first small and painless, but later grew in size and became painful. 



* In the first examination of the growth, I was unable to demonstrate the 
presence of abnormal nerve structure. More recent examinations, however, 
show the existence of the above-described formation. The patient has since 
died. The autopsy, and a study of the disease by Drs. Formad and De 
Schweinitz, corroborating the diagnosis, may be found in Arner. Jour, of 
Med. Sci., Oct. 1881. 

f For a report of the operation, see Amer. Jour, of Med. Sci., July, 1874. 



MYOMA CUTIS. 573 

The affection occupied the posterior and outer sides of the right 
thigh, as far down as the lower third, and a portion of the buttock. 
It was characterized by numerous (about one hundred), dissemi- 
nated, more or less well defined, roundish or ovalish tubercles, vary- 
ing in size from a pin-head to a hazel-nut. They were seated in 
the corium, but extended into the deeper structures. They were 
hard, elastic, and painful to the touch. The larger ones were semi- 
transparent. The skin was dry, uneven, and covered with a slowly 
desquamating, scaly epidermis. Pain was a marked feature of the 
disease, and upon pressure the lesions, more especially the larger 
ones, were intensely painful. Microscopic examination showed 
them to be composed of non-medullated nerve fibres and connec- 
tive tissue. They were found to be supplied by the branches of 
the small sciatic and external cutaneous nerves. All other treat- 
ment having failed, a portion of the small sciatic nerve was ex- 
posed by an oblique incision in the gluteal fold, and an inch 
exsected. The operation was followed by immediate diminution 
of pain. Four months later the lesions had nearly disappeared, and 
were entirely painless. 

Attention has thus been called to two examples of a disease 
which I believe to be entitled to the name under which they have 
been placed. It is without doubt closely allied, clinically as well 
as pathologically, to the affection known as "subcutaneous painful 
tubercle." It differs, however, from this growth, as originally 
described by Wood,* in having its seat primarily in the true 
skin and not in the subcutaneous connective tissue. The subcu- 
taneous painful tubercle, as its name indicates, is situated beneath 
the skin, and is often scarcely perceptible to the eye. It is always 
found to be freely movable under the skin and never in any 
way attached to it. It is, moreover, almost invariably a solitary 
growth. 

Myoma Cutis. — Dermatomyoma, consisting of tumors of the 
skin composed of smooth muscular fibres, also known as liomyoma 
cutis (from Aeloq, smooth), has been described by Yirchow,f Yer- 

*Edin. Med. and Surg. Jour., 1812; and Trans, of Med.-Chir. Soc. of 
Edin., 1829. 

f Ueber cavernose Geschwiilste und Telangiectasien. Archiv fur Path., 
Anat. u. Phys., 1854, Bd. vi. pp. 553, 554. 



574 NEW GROWTHS. 

neuil,* Forster,"f and more recently by Besnier,J of Paris, who has 
published a valuable article on the subject. The disease may occur 
in the form of single or multiple growths localized in a special 
region, as the scrotum or the nipple, as in the cases reported by 
Forster, Virchow, and Challand ;§ or, more rarely, as multiple 
disseminated formations, occupying the trunk and extremities, as 
in the cases recorded by Verneuil and Besnier. 

The true myoma of the skin, or the simple variety of the dis- 
ease, may be illustrated by the following case, reported by Besnier. 
The patient was a woman, sixty years of age. Upon the trunk 
and upper extremities there existed disseminated lesions, consisting 
of pale-rose colored, rounded or ovalish, very slightly raised, bean 
sized macules; together with rose and dull-red colored shot, pea, 
and bean sized, firm tumors, with a smooth surface. There; was 
no itching or pain, except in the case of the larger tumors, which 
were painful on pressure. The disease was of three months' du- 
ration. Microscopic examination showed the growths to consist 
almost entirely of bundles of smooth muscular fibres, of variable 
thickness, forming a close net-work. In a case reported by Solles,|| 
severe pain, spontaneous and provoked by irritation, existed. 
Pressure, blows, and sometimes the mere friction of the clothing 
upon the tumors caused attacks of pain, which, confined at first to 
the part irritated, extended in all directions. With the pain, the 
tumors, which were the seat of pain, became anaemic for the time 
being. Microscopical examination gave the same results as in 
Besnier 's case. The patient also suffered from spontaneous neu- 
ralgic attacks. 

Another and commoner variety of the disease consists of tumor-, 
usually solitary, but sometimes multiple upon a localized region. 
They are encountered upon the mammae, scrotum, penis, and labia, 
as sessile or pedunculated growths, varying in size from a small 
nut to an orange, but are usually the size of an almond or a 
walnut. They are contractile, more or less vascular, of slow 

* Bull, de la SocAnat., 2me Ser., XXXIIP Annee, Aout, 1858, p. 373. 
f Ueber die weichen Warzen und molluskenartigen Geschwiilste der Haut. 
Wiener Med. Wochenschr., No. 9, 1858. 

X Annales de Derm, et de Syph., 2me Ser., t. i. Xo. 1, 1880. 
I Bull, de la Soc. Anat., oe Ser., XLVP Annee, Juillet, 1871. 
|| Annales de Derm, et de Syph., 2me Ser., t. ii. Xo. 1, p. 60. 



MYOMA CUTIS. 575 

growth, and usually painless. There are exceptions to this latter 
statement, as in a case reported by Virchovv,* where the pain was 
of extraordinary intensity. Myoma cutis consists essentially of 
a new formation of involuntary, or smooth, muscular fibres. It 
may, however, vary greatly in its composition. At times it is 
made up largely of connective tissue, constituting fibromyoma ; 
in other cases bloodvessels prevail to such an extent as to give 
rise to cavernous, erectile tumors, designated by Virchow myoma 
telangiectodes. The disease is benign in character, and is rare. 
It is liable to be confounded with various benignant cutaneous 
tumors, especially with molluscum fibrosum. 

i* Loc. cit. 



CLASS VIII. 

NEUROSES. 

Under the head of neuroses are classed those disorders which 
are characterized by an alteration in the normal sensibility of the 
skin unattended by structural change. They are strictly functional 
in character, and depend upon an altered state of the nervous 
system, manifesting itself directly upon the cutaneous surface. 
The symptoms of neuroses, consequently, are purely subjective, no 
structural lesions or other objective symptoms primarily existing. 
Secondary lesions, however, as scratch marks or artificial hyper- 
emia, may be produced, and must be viewed as consequent upon 
the original disturbance. The affections which are found in this 
class may be grouped into two divisions, termed hyperesthesia 
and anaesthesia. 

HYPERESTHESIA. 

Cutaneous hyperesthesia consists in an abnormal state of the 
skin characterized by an augmentation in its general sensibility. 
It may be idiopathic or symptomatic; the latter variety is that 
usually encountered, the condition being secondary and manifestly 
dependent upon some more serious disease. Simple augmented 
natural sensibility, or simple hyperesthesia, may be either general 
or local, diffused or circumscribed, and unilateral or symmetrical. 
The temperature, as a rule, remains normal. The causes are 
varied, the condition being due either to some functional derange- 
ment of the nervous system, or to some organic disease connected 
with the nerve centres or trunks. Hysteria and allied states are 
well-known causes; also diseases of the brain, spinal cord, and 
nerves. The sensation in the parts is unduly exalted, the patient 
experiencing discomfort from contact with the air, clothes, and 
other objects. The skin is often exquisitely sensitive to all impres- 
576 



DERMATALGIA. 577 

sions. In duration it may be permanent or temporary, according 
to the cause which has occasioned it. 



DERMATALGIA. 

Syn., Dermalgia ; Neuralgia of the Skin ; Rheumatism of the Skin ; Germ., 
Nervenschmerz der Haut ; Fr., Dermalgie. 

DERMATALGIA IS CHARACTERIZED BY PAIN HAVING ITS SEAT 
SOLELY IN THE SKIN, ASSOCIATED USUALLY WITH A MORBIDLY 
SENSITIVE CONDITION OF THE PART, UNATTENDED BY STRUCTURAL 
CHANGE. 

Symptoms. — The subject of dermatalgia has received especial 
attention from Piorry,* Beau,f and Axenfeld.J The symptoms 
are entirely subjective. There is absolutely nothing abnormal to 
be seen upon the skin. It presents no sign of eruption, nor is 
there any alteration in its thickness, coloration, or temperature. 
The disease may be general or local ; ordinarily it is confined to 
a small area. All parts of the body may be invaded; but it has 
preference for the parts supplied with hair. It is generally en- 
countered in adult age, and is more frequently observed in women 
than in men. It is described by patients as consisting of an ex- 
tremely sensitive state of the skin, accompanied by a feeling of 
positive pain, which is peculiar in that it has its seat in the most 
superficial layers of the integument. The attack is often sudden. 
The surface • becomes remarkably sensible to all external impres- 
sions, the touch, and even the influence of the air, exciting pain. 
In addition, the part is the seat of a spontaneous pain, which may 
be either constant or intermittent in character. It may be slight 
or severe in degree, and in the several cases that I have en- 
countered has been compared to sensations of burning, pricking, 
shooting, or boring. Sometimes it is said to resemble a series of 
electric shocks. It has also been described as though the part had 
been denuded of epidermis and the papilla? allowed to remain ex- 
posed to the air. Contact, as well as motion, always increases the 
pain, the rubbing of the clothes, or the mere touch of the finger, 

* Memoire sur la Nature et le Traitement de plusieurs Nevroses. Paris, 
1835. 

f Arch. Gen. de Med., t. xii. Paris, 1841. 
+ Des Nevroses. Paris, 1864. 

37 



578 NEUEOSES. 

being sufficient to produce it. Gentle manipulation of the part 
in some cases causes a greater degree of pain than pressure. Firm 
and forcible pressure will sometimes relieve it. It is usually worse 
at night, and may be so severe as to prevent sleep. The course of 
the disease is indefinite. Relapses may occur. 

Two forms of dermatalgia are encountered, which may be des- 
ignated respectively idiopathic and symptomatic. In the former 
the cutaneous symptoms exist apparently as the primary and 
sole disease, while in the latter, diseases of other organs primarily 
occur, as, for example, lesions of the nervous centres (for example, 
locomotor ataxia), upon which the skin affection is manifestly 
dependent. The idiopathic form is very rare; the symptomatic 
is more common. 

Etiology. — The causes which occasion the idiopathic form are 
generally obscure. Its connection with rheumatism in some cases 
has been pointed out by Beau. This writer, indeed, considers 
that the majority of cases are of a rheumatic nature. In most 
of the recorded examples of the affection there certainly has been 
a history of rheumatism, either recent or remote; but it occurs 
also In those apparently in the best of health, as I have observed 
in several instances. It is not confined to those of nervous tem- 
perament. Jt sometimes follows a general impression of cold. 
The symptomatic form may be caused by a number of diseases, 
especially organic diseases of the brain and spinal cord. Hysteria 
is also one of the more common causes, and it is likewise known 
to accompany chlorosis.* 

Pathology. — From the character of the pain in idiopathic der- 
matalgia there can be no doubt that the disease has its seal in 
the upper layers of the true skin. It is remarkably superficial, 
and does not, as a rule, appear to extend even as far down as the 
subcutaneous tissues. A- Axenfeld remark-, in addition to the 
location of the pain by the patient, its exasperation caused by the 
slightest touch proves conclusively that it is actually situated in 
the skin, and not simply referred there by the nervous centres. 

Diagnosis. — It may be confounded with simple hyperaesthesia, 
but this condition usually extends over considerable surface and 

* See Mordret, Prager Viertelj., vol. Ixxiii. p. 87; also Briquet, Traite eli- 
uique et therapeutique de l'Hysterie, Paris, I - 



PRURITUS. 579 

is unaccompanied by pain. It will be distinguished from pruritus 
by the usually limited area of surface attacked, and by the pres- 
ence of pain instead of itching. It should not be confused with 
pains in the nerve trunks, with ordinary neuralgias, situated in 
the deeper structures, or with muscular pains. 

Treatment. — This will depend upon whether it be idiopathic 
or symptomatic in form, and more particularly upon the cause. 
Rheumatism should always be suspected, and in obstinate cases 
diseases of the nerve centres should be looked for. In the idio- 
pathic form the disease may disappear at the end of a few weeks 
either with or without treatment. Local applications, however, 
may be demanded to relieve the acute symptoms. A blister to 
the part, as recommended by Beau, may be tried. The galvanic 
current, and applications containing the tincture of belladonna, 
of aconite root, or of iodine, may also be referred to as likely to 
prove serviceable. Vapor baths may be employed where the 
disorder is general. 

PRURITUS. 

Pruritus is a functional cutaneous affection, manifesting 
itself solely bt the presence of the sensation of itching, 
without structural alteration of the skin. 

Symptoms. — It may be stated, in the first place, that the various 
forms of itching encountered in the course of many diseases of 
the skin accompanied by organic change, are in no way associated 
with the disorder under consideration. These have been men- 
tioned and discussed in connection with the diseases in which they 
occur. Pruritus stands forth a prominent and distinct affection. 
As stated, the single primary symptom is itching, there being iro 
primary objective symptoms whatsoever; secondary lesions may 
or may not exist, their presence depending upon the amount of 
irritation and scratching to which the skin has been subjected. 

The sensation is variously described, as it is dependent upon one 
cause or another, and according to the region involved. Some- 
times it is spoken of as a simple irritation of the skin, as though 
some irritating substance were in contact with the body, as, for 
instance, new flannel. ■ In other cases it is that of formication, as 
though minute insects were crawling over the surface. Again it 
is a tingling sensation, accompanied by a desire to scratch. In this 



580 NEUROSES. 

manner, according to the subjective condition of the individual, 
it may be likened to an endless variety of sensations. It exists 
in all degrees of severity, from a slight annoyance to a miserable 
disease. It may occur at any age, but' is most frequently met 
with in middle life, and in old age, when it is designated pru- 
ritus SENILIS. 

One characteristic of the itching, in all cases, is that it produces 
an irresistible desire to scratch. This act, or a modification, rub- 
bing, is invariably indulged in to a greater or less extent, and 
can rarely be refrained from in spite of the strongest will. As a 
result, the surface is generally seen to be slightly roughened, hy- 
persemic, and excoriated in a slight or marked degree, the tracks 
of the nails being visible in the form of streaks or superficial 
wounds. In other cases, nut withstanding the scratching, but few 
excoriations or marks are to be observed, so that were it not for 
the statement of the patient we might be inclined to doubt the 
presence of any disorder. The itching may be intermittent or 
constant. In the majority of cases it is the former, manifesting 
itself paroxysmal] v. It is always worse at night. 

Pruritus may be general, when it is designated PRURITUS UNI- 
VERSALIS, or local, when it is termed PRURITUS LOCALIS. It 
rarely, however, invades the whole surface at the same time, al- 
though the various regions of the body may in turn be attacked. 
In most cases certain localities are chosen, where it remains until 
it disappears either spontaneously or through treatment. About 
the head it may attack the scalp or the face; when upon the face, 
the nose and mouth are particularly liable to be involved. The 
trunk is also often the seat of the disease, especially in elderly 
persons. The regions commonly attacked, however, are the geni- 
talia and anus. 

Occurring about the female genital organs, constituting the 
pruritus vulvae of writers, it is important not to confound it 
with other diseases of an itching character which are apt to appear 
in this locality. The itching may be seated in the labia, vagina, 
or clitoris, and is a very distressing affection. It may occur at 
any period of life, but it is more frequently encountered during 
middle and old age. In children it is often caused by worms in 
the bowel. 

In the male, the scrotum is the part generally attacked (pru- 



PRURITUS. 581 

ritus scroti). It may involve this region alone or may extend 
along the perineum to the anus. The orifice of the urethra may 
also be the seat of the disease. The sensations are usually intensely 
annoying, causing the patient to rub and scratch violently. It is 
worse at night, and, being aggravated by warmth, is apt to come 
on after retiring. 

The anus is also a frequent seat of the disorder (pruritus 
ANi). It occurs here in both sexes, and in children as well as in 
adults. The itching may be around the orifice or just within the 
rectum. In middle-aged or elderly persons it is not infrequently 
associated with hemorrhoids. It is even more intolerable than 
any of the other local varieties. At times it is constant, but 
more often it comes and goes from time to time, but is particu- 
larly annoying at night. 

Etiology. — The causes are extremely varied, and it is necessary 
to bear this in mind when investigating a case. It may be occa- 
sioned by physiological changes, as, for instance, those which take 
place in connection with the uterus during gestation, or by dys- 
menorrhoea, or by irregularity of the menstrual function in young 
women. Organic diseases of the uterus and ovaries are also at 
times accompanied by it. It is also met with at the climacteric 
period. Occasionally it is associated with hysteria. Leucorrhoea 
and vulvitis are likewise common causes. It is, moreover, en- 
countered in the course of certain other diseases, kidney diseases 
and hepatic disorders, especially the latter, being not infrequently 
productive of it. It is met with in albuminuria, Bright's disease, 
and diabetes. In obstinate cases sugar may be suspected, diabetes 
mellitus being a not infrequent cause. The urine should always 
be examined. Pruritus accompanying jaundice is common. Fre- 
richs estimated that it occurs in about one-fifth of the cases, while 
Wickham Legg* states that he meets with it in sixty -eight percent, 
of the cases of jaundice. It is usually general, and is worse at 
night. Sometimes it precedes the jaundice. In rare cases it may 
manifest itself weeks or even several months before the jaundice, as 
in instances reported by Graves,f Flint,! and Legg.§ As a rule, 



* On the Bile, Jaundice, and Bilious Diseases. New York, 1880. 
f Clin. Lect. on the Pract. of Med, 2d. ed., p. 637. Dublin, 1864. 
X Phila. Med. Times, 1878, vol. viii. p. 507. I Loc cit. 



582 NETTJROSES. 

according to Legg, it is most intense at the outset, ceasing when 
the jaundice has lasted a few days. It is, however, often very 
obstinate, and may prove a distressing symptom. It may occur 
also in hepatic disorder without jaundice. Its cause is not defi- 
nitely known. According to Murchison, it is probably not caused 
by the circulation of bile-pigment. 

Various diseases of the nervous system are likewise found to be 
the origin of pruritus. Very often it is caused by gastro-intestinal 
derangement, especially constipation. Genito-urinary diseases, as 
vesical calculi and vegetations or polypi of the urethra, in both 
sexes are also well-recognized causes ; also hemorrhoids and intes- 
tinal worms, especially ascarides. In the latter cases the pruritus 
is apt to locate itself immediately about the seat of the disease. 
The ingestion of certain medicines may likewise be followed by 
pruritus opium occasionally acting in this manner. It is, of 
course, distinctly understood that the affection under discussion 
is in no way caused by parasites, either animal or vegetable. 
Pediculi may be present in pruritus, but if so the fact is to be 
regarded as entirely accidental. 

Pathology.— Pruritus is a functional affection. It is a disease 
purely of sensation. It mint be viewed as being usually due to 
reflex nervous action. The nerve disturbance, unaccompanied by 
structural change, constitutes the whole process. The tissues 
remain unaltered throughout the entire course of the disorder. 
The causes which give rise to it arc often similar to those which 
occasion certain organic cutaneous diseases, as, for instance, urti- 
caria; but the effect upon the skin is altogether different. In rare 
cases pruritus gives rise to peculiar hallucinations and subjective 
symptoms, as in a case reported by me where the patient believed 
the skin to be infested by worms.* 

Diagnosis.— Xo difficulty can arise in distinguishing the affec- 
tion. It is a disease of the skin without any primary sign of 
alteration in its structure. Nothing abnormal is to be seen, except 
secondary lesions. The diagnosis depends entirely upon the sub- 
jective symptoms stated by the patient. Pruritus begins and runs 
its course as such. Occasionally, owing to violent scratching and 
the use of strong applications, more or less dermatitis may be 

* Phila. Med. Times, Xov. 27, 1875. 



PEURITUS. 583 

brought on. Thus, scratch marks, torn follicles, blood crusts, 
roughened epidermis, hypersemia, congested follicles resembling 
papules, and other symptoms of a similar kind, may be present; 
but they are all secondary lesions. The complication, however, 
in my experience, is not often encountered. 

Prurigo, a name which until recently served for several distinct 
diseases, is now acknowledged to represent a definite process.* It 
is a papular affection, with marked symptoms and a determinate 
course. Bearing in mind its papular nature, therefore, it should 
never be confounded with pruritus. Pruritus and prurigo must 
be clearly separated, the only symptom they have in common 
being one found accompanying many cutaneous diseases, namely, 
itching. 

Pruritus may also be confounded with the several varieties of 
pediculosis, especially corporis and pubis. The secondary symp- 
toms of these diseases are similar, and it is concerning these lesions 
that the error is apt to arise. In both complaints there are itch- 
ing and scratch marks ; but the latter are much more marked in 
pediculosis, and the presence of the pediculi establishes conclu- 
sively the diagnosis. The scratch marks and excoriations of 
pruritus are rarely extensive ; in pediculosis they are not only 
conspicuous but are also characteristic as regards their distribution 
and form. Thorough inspection of the body, and especially of 
the underclothes, is necessary in making the examination; the 
parasites should be suspected in every case of so-called "pruritus." 
In obscure cases of pruritus of the pudenda in the female, a care- 
ful examination should be made of the labia and vagina, with the 
view of excluding the presence of unsuspected growths or tumors 
of one kind or another, which are capable of giving rise to the dis- 
ease. Inversion of the hairs of the labia should also be excluded. 

Treatment. — This must vary according to the cause. Each case 
should receive careful investigation, for a successful result will 
depend upon the recognition of the cause, Constitutional and 
local treatment are both demanded. The internal remedies to be 
employed are those which seem indicated for relieving the cause, 



* Confusion has long existed between pruritus, prurigo, and pediculosis 
but, as may be seen by reference to the descriptions of these diseases, they ai 
very different disorders as regards both their symptoms and their causes. 



584 NEUROSES. 

of whatever nature this may prove. The bowels are to be regu- 
lated, and, if habitual constipation exist, they are to be kept open, 
saline preparations being preferable. If there be flatulence or 
dyspepsia, the diet should be prescribed with a view to avoiding 
all irritating and indigestible articles of food. Wine, coffee, and 
tea should, as a rule, be interdicted. Proper exercise is also to be 
directed. Close attention to details of this kind will occasionally 
be followed by most gratifying results. Irregular menstruation is 
to be improved by attention to the general health, by the judicious 
use of iron or other remedies, cod-liver oil, aperients, and out-door 
recreation. Quinine, strychnine, and belladonna may be men- 
tioned as being sometimes useful. When accompanying diseases 
of the kidney or liver, the treatment is to be directed against these 
organs, nor is much improvement to be hoped for until the primary 
disease has been relieved. Murchison* speaks highly of the value 
of bicarbonate of potassium when the itching is due to jaundice. 
These remarks apply equally to affections of the nervous system 
and of the geni to-urinary tract. In these cases the pruritus is 
purely symptomatic. Where the internal difficulty is of an organic 
kind, it is not likely that the cutaneous complaint will be relieved 
until the cause has been at least modified. Carbolic; acid is also a 
remedy of some value, administered a- described in considering 
psoriasis. Bulkleyf speaks favorably of the tincture of gclsemi- 
num, in fifteen drop doses every half hour until from our to two 
drachms have been taken. Pilocarpin is also recommended by 
Pick,;J; given by the mouth or hypodermically, in doses from an 
eighth to a quarter of a grain twice daily. 

External treatment in the majority of cases is scarcely to be 
looked upon as curative, but affords great relief, and in all cases 
is demanded. Water in the form of cold or hot douches, or 
alternately cold and hot, as hot as the skin will bear, plain vapor 
baths, and medicated baths, will often prove of service in allaying 
the symptoms. The alkaline bath, composed of from three to 
six ounces of the bicarbonate of sodium, or of from two to four 
ounces of the carbonate of potassium or of borax, to thirty gallons 
of water; and sulphuret of potassium, from one to four ounces to 



* Loc. cit. f New York Med. Jour , Jan. 1881. 

X Abstract in Phila. Med. Times, vol. x. p. 4~s2. 



PRURITUS. 585 

the bath, and sulphur vapor baths, may all be mentioned as being 
useful. Benefit may often be derived from the use after the bath 
of one of the bland oils, as oil of sweet almond or olive oil, or 
from simple ointments, as equal parts of one of the petroleum oint- 
ments and lard or glycerine; also glycerole of starch or of tannin. 
Lotions are to be commended as especially serviceable in the 
treatment of the local varieties of the disease. The most valu- 
able remedy is carbolic acid, employed in the strength -of from 
five to twenty minims to the ounce, to which may be added half a 
drachm or more each of glycerine and alcohol. The disagreeable 
odor is best disguised with water of bitter almond or with oil 
of lemon. It may also be used with potassa, as in the following 

prescription : 

I£ Acidi Carbolici, gi ; 

Potassas, £ss ; 

Aquae, f^viii. 
M. 

Thymol, prescribed as in eczema, has also proved useful in my 
hands. The corrosive chloride of mercury in the form of a lotion, 
half a grain to two or three grains to the ounce of water or diluted 
alcohol, may frequently be resorted to with benefit. Black wash, 
and lime-water, may likewise be used. Folsom speaks of having 
obtained good results from the essence of peppermint where other 
well-known remedies failed ; and Taylor also refers to its employ- 
ment with an equal part of glycerine, painted on the part with a 
brush. Morphia, from one to three grains to the ounce; acetate 
of lead, fifteen or twenty grains to the ounce; cyanide of potas- 
sium, from fifteen to thirty grains to the pint ; sulphite of sodium, 
a drachm to the ounce; dilute hydrocyanic acid, from one to four 
drachms to the pint; chloroform; chloroform and alcohol, a 
drachm to the ounce; lead- water; diluted water of ammonia; 
dilute nitric acid ; and acetic acid ; are all serviceable remedies. 
Camphor, chloral, and borax are likewise three useful substances, 
employed with water or alcohol, or in various other combinations. 
The following formula may be given : 

R Boracis, gii ; 

Glycerin*, fgi; 

Spts. Camphorse, f2;ss ; 

Aquae Kosse, f^viss. 
M. 



586 NEUROSES. 

A chloral lotion, varying in strength from ten to thirty grains to 
the ounce, may often be employed with good result. Borax and 
morphia are advantageously combined, as, for example, in the 
following, useful in pruritus vulvae. The parts should first be 
washed with soap and water and gently dried. 

R Boracis, giv ; 

Morphia? Sulphatis, gr. viii ; 

Glycerins, f^ss ; 

Aquae, fjviiss. 
M. 

Tobacco, in the form of infusion or decoction, and infusions 
or decoctions of white hellebore, belladonna, and aconite, are all 
useful. R. W. Taylor* recommends the following: 

R Fol. Belladonna, 

Fol. Hyoscyaini, &a Jjii ; 

Pol. Aconiti 

Acidi Acetici, fgi. 
M. 

It Bhould be diluted with water, a drachm to the ounce. It 
may also be used with glycerine, equal parts, painted on the parts; 
or as an ointment, a drachm or two to the ounce. The fluid ex- 
tract of conium, applied by means of a brush, is also recommended 
by Dr. Satterlee. Tar combined with an alkali, as in the "liquor 
picis alkalinus," is sometimes found to be valuable; one, two, or 
more drachms to the pint may be used. (For formula, see ]>. 204.) 
An alcoholic solution of coal tar, in the form of the "liquor car- 
bonis detergens" (see p. 199), may also be mentioned. 

In some instances ointments relieve more effectually than lotions, 
especially in the localized forms of the disease. They are pre- 
pared in various combinations, chiefly from the substances which 
have been mentioned. Carbolic acid, ten or twenty minims to the 
ounce of vaseline ; calomel, half a drachm or a drachm to the 
ounce; cyanide of potassium, five to fifteen grains to the ounce; 
chloroform, a drachm to the ounce; are all especially useful in 



* On the various forms of pruritus cutaneus and their treatment. Arch, 
of Clin. Surg., Aug. 1877. 



PRURITUS. 587 

pruritus of the genitalia and anus. The following formula, 
valuable in pruritus vulvae, may be given: 

R Ungl. Cetacei, §i ; 

Hydrargyri Chloridi Mitis, gss ; 

Ext. Belladonnse, gi. 
M. 

A preparation, introduced to the profession by Bulkley, com- 
posed of camphor and chloral, according to the following formula, 
will often be found of service : 

B Camphorse, 

Chloralis Hydratis, aa gi ; 

Ungt. Aquae Bosse, §i. 
M. 

The camphor and chloral are to be rubbed together until fluid, 
and then added to the ointment. The mixture may also be 
used with vaseline or cosmoline, or as a lotion with glycerine and 
water. 

In pruritus of the female genital organs it is generally advisable 
to use fluid preparations, in the form of vaginal injections, or 
applied by means of a tampon or cloth. Sometimes hot water, 
as hot as can be tolerated, will be found effective. Atthill and 
Goodell both regard the decoction of tobacco, in the strength of 
two drachms of the leaf to the pint, as one of the most valu- 
able remedies in these cases. Bazin recommends the following : 

R Liq. Calcis, 

Glycerinse, aa f^i ; 
01. Amygdalse Duleis, fgii ; 
01. Kosmarini, gtt. v. 
JVI. 

Gill speaks well of the nitrate of alumina, five or ten grains to 
the ounce of water. Sulphurous acid is also valuable; likewise a 
solution of chlorate of potassium. Alum, fifteen or thirty grains 
to the pint of decoction of barley, will sometimes be found useful. 
A prescription containing sulphite of sodium, one drachm; water, 
four drachms; and glycerine, one ounce, pencilled upon the parts, 
may also be referred to. Balsam of Peru, either alone or with 



588 NEUROSES. 

iodoform, as an ointment, is a remedy which will also prove of 
decided value in some cases; while in other cases an ethereal solu- 
tion of iodoform in the form of a spray may afford relief. 

In the treatment of pruritus ani ointments will generally be 
found of most value. The various bland oils, especially cod-liver 
oil, are also sometimes serviceable. Bulkley recommends equal 
parts of mercurial ointment and belladonna ointment, applied 
upon a pledget of lint. Where there are fissures, pencilling with 
a solution of the nitrate of silver will often prove beneficial. The 
application of very hot water, as hot as can be borne, applied 
with a soft linen compress, Will itself sometimes afford ease, and 
may be used before other remedies are employed. In pruritus 
scroti Bulkley obtains good results from the following prescription : 

R Bismutbi Subnitratis, ,~ii ; 

Acidi Hydrocyanici, fjiij 

Mist. Amygdala', f^iv. 
M. 

Legg thinks he has derived more benefit in pruritus due to jaun- 
dice from the use of the mercurial ointments, especially calomel 
and white precipitate, than from any other remedies. Murchison 
in these cases valued lotions of chloroform (one drachm to five of 
glycerine) and cyanide of potassium (one drachm to the pint) ; 
and acetic acid baths or lotion-, in the Btrength of half a pint of 
the acid to three gallons of water. 

Prognosis. — This should always be guarded. The disorder, as 
a rule, is obstinate, and often extremely so. The prognosis musl 
depend entirely upon the nature of the cause, and the ability to 
remove it. The patient should be encouraged to persevere with 
the treatment. In grave cases, melancholic symptoms and mental 
depression may be present The affection is a most distressing 
one, and calls for every effort on the part of the physician. 

Pruritus Hiemaus. — With this name I described for the 
first time* a peculiar disorder of the skin, characterized by an 
irritable, somewhat harsh state of the skin, accompanied by itching, 
smarting, tingling, and burning, unattended primarily by appar- 

* Phila. Med. Times, Jan. 10, 1874. 



PRUBITUS. 589 

ent structural change, dependent upon atmospheric influences, and 
occurring chiefly in cold weather. It makes its appearance in the 
autumn, usually in October, and, becoming worse with the colder 
weather, continues, as a rule, until spring. It may appear grad- 
ually or suddenly. The amount of irritation varies ; it may be 
slight or so severe as to cause much annoyance. It possesses the 
peculiarity of becoming aggravated towards night, usually as the 
patient is about to retire, and is at its height, as a rule, shortly 
after the bed has been entered. The desire to scratch is irresistible, 
and the individual gratifies the craving either until some relief is 
obtained or sleep terminates the distress. Upon awaking in the 
morning, itching may again manifest itself, but generally it is in- 
significant, and often no further thought is given the subject until 
the following evening, when the symptoms reappear. Sometimes, 
in mild cases, no itching whatsoever is experienced through the 
clay. Should a period of mild or warm weather occur, the symp- 
toms at once improve or for the time may even disappear. At 
the end of an indefinite period, usually months, it gradually van- 
ishes. The patient now remains free until the next autumn, when 
in all probability it will recur and run a similar course. It may 
relapse in this way year after year, or it may disappear at the end 
of the first attack, not to return. In mild winters it assumes a 
correspondingly light type. 

There is no primary eruption connected with the disorder, either 
at the beginning or at any time during its course. If the skin 
be examined, nothing indicative of disease is to be detected. It 
looks healthy, with the exception that it is perhaps somewhat 
dry, but the glandular secretions do not seem to be markedly de- 
ficient. The epidermis is normal, there is no desquamation, and 
the parts are neither hyperaemic nor warm. The hair-follicles 
are neither inflamed nor prominent, there being no accumulation 
about their openings. In short, the subjective symptoms which 
the patient communicates alone convey any idea of the disorder. 
If, however, the skin be seen after the complaint has existed for 
some time, it will look otherwise than described. Marked sec- 
ondary symptoms now exist. The skin may be rough and harsh 
or slightly chapped, sore, and reddish, and, many of the follicles 
more or less inflamed, giving rise to minute papules. The hairs 
may also be torn and broken off close to their follicles. Here and 



590 NEUROSES. 

there, generally over a considerable surface, the skin looks irritated 
and inflamed, the result of scratching. The marks of the finger- 
nails are also usually everywhere present, in the form of streaks 
and variously sized excoriations and blood crusts. In severe cases 
a general dermatitis of the thighs and legs may be present, the 
follicles being notably involved, and the subjective symptoms are 
marked. 

All parts of the body may be attacked, although it is found 
much more frequently upon certain regions. It is confined chiefly 
to the lower extremities, its usual scat being upon the inner sur- 
faces of the thighs, about the knees, in the popliteal spaces, upon 
the calves of the legs, and around the ankles. Thus, the non- 
hairy portions of the limbs are selected in preference to the hairy 
parts. It is not a localized affection. The symptoms may lie 
most marked here or there, as the ease may be, or may change 
from one locality to another. It- duration is variable. In some 
cases it lasts but a few weeks, while in other instances it remains 
until the advent of warm weather. Not infrequently it abates in 
severity alter the first lew weeks. A change of weather from 
cold to warm will also greatly relieve the disorder. It is a com- 
mon complaint in cold and temperate climates, and is found upon 
individuals of all ages, no particular period of lite being more 
susceptible than another. It occurs in both se\ 

Concerning the etiology of the affection, it is known to be in- 
timately associated with atmospheric influences. It i- emphatically 
a disorder of the cool weather, disappearing as Boon as the warmer 
season establishes it-elf. f have Been a few cases, however, where 
it persisted well into hot weather. It is mosl common in northern 
climates, decreasing in frequency and in degree as the south is 
approached. The general health is in no way at fault. It occurs 
frequently in persons in excellent health. While derangement of 
the alimentary canal or other functional disturbance may exist, 
such conditions cannot be viewed as causing the disease. It is 
found equally among those who live in luxury and those dwelling 
in poverty. It is not caused, or in any way influenced, by inat- 
tention to cleanliness, for it exists in no greater proportion among 
the unwashed than among the cleanly, it being as frequent among 
bathers as among those who never use the bath. Nor is it due to 
any peculiarity in the underclothes worn, neither flannel, woollen 



ANESTHESIA. 591 

wear, nor rough goods of any description being the direct cause, 
although when used they of course aggravate the condition. Ex- 
ternal irritation, therefore, has no share in the primary cause. In 
its secondary stage, after long-continued scratching, it is liable to 
be confounded with other diseases ; thus, it may be mistaken for 
keratosis pilaris, prurigo, and pediculosis. 

"While certain external remedies relieve the condition for a 
time, they cannot be relied upon to effect a cure. The treat- 
ment, upon the whole, is not satisfactory. The most relief is to 
be obtained from the use of glycerine, vaseline, or cosmoline, the 
various emollient ointments, carbolic acid, and the tarry prepara- 
tions, in the form of lotions or ointments. Glycerine is the most 
valuable remedy, in the form of a lotion or as an ointment. Al- 
kaline baths, from two to six ounces of bicarbonate of sodium to 
the bath, and the systematic use of the vapor bath, will at times 
give relief. The parts should be gently dried with a soft towel. 
The undergarments worn should be of an unirritating nature. 
The various other prescriptions, lotions, and ointments referred to 
in the treatment of the other forms of the disease may also be 
used. Internal treatment is of no avail, except perhaps where 
manifest functional derangement of internal organs exists. 

ANESTHESIA. 

Cutaneous anaesthesia is characterized either by diminished sen- 
sibility or by an absolute want of sensibility. It varies greatly 
in the degree of its development. It may be general or local ; 
diffused or circumscribed. In the majority of cases it is confined 
to certain regions. It may be unilateral or symmetrical. It 
manifests itself by the absence rather than by the presence of 
symptoms. The integument so affected is numb, or may be com- 
pletely without feeling. It may or may not be accompanied by 
diminution of temperature, arrest of nutrition, and other signs of 
nerve disturbance, symptoms of this character being present or 
absent according to the cause. As a modification of anaesthesia 
there exists the condition known as " analgesia" or " anodynia," 
in which there is loss of sensibility to pain. It may be partial or 
complete; when complete, there is absolute immunity from pain, 
to such a degree that a pin may be thrust through the tissues 



592 NEUROSES. 

without giving rise to suffering. It may exist alone, without 
anaesthesia, tactile sensibility being preserved; or it may occur 
together with anaesthesia, in which case loss of sensibility both 
to touch and to pain is present. It is encountered in syphilis and 
in other diseases. 

Cutaneous anaesthesia may be idiopathic or symptomatic. Its 
causes are numerous and diverse in nature; they may be divided 
into those having a central origin, and those which act from 
without. To the latter belong all those agents which are capable 
of producing local anaesthesia, as cold, freezing mixtures, carbolic 
acid, chloroform, ether, caustics, aconite, and other substances pos- 
sessing like properties. Anaesthesia may also result from trau- 
matism, wounds, and injuries to nerves, not infrequently being 
followed by more or less complete loss of sensibility. Certain 
diseases in which the nerves become involved by the morbid 
process are also accompanied by ansesthesia, as in leprosy and 
syphilis; likewise tumors of one kind or another, pressing upon 
nerve trunks. Diseases of the nervous system, both functional 
and organic, as, for example, hysteria and diseases of the brain 
and spinal cord, are also not infrequent causes of ansesthesia. 
Finally, loss of sensibility may arise from the toxic effects upon 
the system of certain substances; of these, chloroform, ether, 
opium, and lead may be mentioned. 

In certain cases of ansesthesia, to which the name "ansesthesia 
dolorosa" has been applied by Romberg, the patient suffers from 
intense pain, although there ma*' be complete loss of all forms of 
sensibility. It may be burning, shooting, darting, or boring in 
character. The affection is met with especially about the region 
of the trigeminal nerve, and is probably always symptomatic of 
organic disease of the nerve centres. 



GLASS IX. . 
PARASITE— PARASITES. 

This class stands upon an etiological basis. The diseases con- 
stitute a natural, intelligible, and satisfactory group. The so-called 
parasites of the skin belong to the vegetable and animal kingdoms, 
and are termed respectively vegetable and animal parasites. They 
derive their sustenance from the cutaneous tissues, and have their 
habitat either in the texture of the integument, as in the case 
of fungi and in scabies, or upon its surface, strictly speaking, as 
in pediculosis. The diseases due to the presence of a vegetable 
organism or fungus are designated by the generic term " tinese" : 
they comprise tinea favosa, tinea circinata, tinea tonsurans, tinea 
sycosis, and tinea versicolor. The two important animal parasitic 
affections are scabies and pediculosis. 

The parasitic diseases of the skin occupy a prominent place in 
dermatology. They are met with everywhere ; they occur, how- 
ever, more frequently in some countries than in others. They are 
more common in populous, overcrowded cities than in the country. 
They are local affections, and consequently are amenable to exter- 
nal treatment. They are all contagious, although by no means so 
to the same degree ; some are highly contagious, while others are 
so only under certain circumstances. As a group they incline to 
pursue a chronic course, and may continue for an indefinite period. 
They are all curable, and are relieved by a class of remedies 
known as parasiticides. 

TINEA FAVOSA. 

Syn., Favus ; Porrigo Favosa; Crusted Eingworm ; Honey-comb King- 
worm; Germ., Erbgrind ; Fr., Teigne Faveuse. 

Tinea favosa is a contagious, vegetable parasitic disease, 
DUE to the achorion schonleinii, characterized by discrete or 

CONFLUENT, SPLIT-PEA SIZED, CIRCULAR, CUP-SHAPED, PALE-YELLOW, 
FRIABLE CRUSTS, USUALLY PERFORATED BY HAIRS. 

Symptoms. — The disease may attack the hairs and follicles (tinea 
38 593 



594 PARASITES. 

favosa pilaris), the epidermis (tinea favosa epidermis), or the nails 
(tinea favosa unguium) ; occasionally all of these structures are 
invaded at the same time. Its usual seat is the scalp. Other por- 
tions of the integument, however, non-hairy as well as hairy regions, 
are also not infrequently invaded ; for example, the shoulders, 
arms, penis, scrotum, and thighs. It manifests itself at first In- 
diffused or circumscribed superficial inflammation with slight 
scaling, followed by the appearance of one or of several pin-head 
sized, pale-yellow crusts, seated about the hair-follicles. In the 
course of a fortnight they will have increased considerably in size, 
and are then to be recognized with the naked eye as well-formed 
" favus cups" or "favi," presenting the following characteristics. 
They consist of a peculiar, dry, crust formation. They are cir- 
cumscribed, circular in form, and are elevated from half a line to 
several lines above the level of the skin. In their early stage 
they are bound down to the skin by a layer of epidermis, which 
surrounds and overlaps their periphery. Later, when the crust 
assumes size, this attachment breaks, leaving the edges of the crust 
free and above the level of the epidermis. They arc cup-shaped, 
possessing marked umbilication, through which one or more hairs 
usually protrude. In structure they are made up of a series of 
concentric layers compactly arranged one upon the other. In 
consistence they are firm, and in m< »~t cases retain their form until 
destroyed by violence. When taken up between the fingers they 
are more or less friable, and often crumble under pri ssure, like 
dry mortar. Owing to the concentric laminae, their surfaces are 
uneven; and not infrequently, from external causes, they are 
injured and broken, and then present a rough exterior. 

Their color is pale yellow or sulphur-yellow. If they have ex- 
isted for some time, the brightness of the hue will have become 
tarnished by the deposit of extraneous matter, as dust or appli- 
cations which may have been used, and they will then possess a 
brownish- or greenish-yellow color, similar to that observed in 
pustular eczema. They arc seated superficially upon the integu- 
ment, and may usually be raised from their bed without difficulty. 
The skin beneath is depressed, smooth, and shining or atrophied ; 
often covered with a delicate layer of epidermis ; hypersemic or 
inflamed ; or in a state of suppuration. In old cases, where the 
skin is much irritated, pustules and suppuration not infrequently 



TINEA FAVOSA. 595 

occur beneath and around the edges of the crusts. The amount 
of disease and the number of crusts present vary ; it is usual to 
meet with discrete lesions as well as with patches composed of two 
or more which have coalesced, forming irregularly-shaped masses, 
having somewhat of a honey-comb appearance. The size of the 
favi varies according to their age ; as ordinarily seen, they are about 
the size of split peas. 

Any part of the body may be the seat of tinea favosa ; the scalp, 
however, as already stated, is its usual habitat.* Occurring here, 
the disease is sometimes complicated with pediculi, while swelling 
of the glands of the neck, and small abscesses upon the scalp, are 
not uncommon. The general surface of the body may also be at- 
tacked, either together with the scalp or alone. In rare instances, 
as in a case depicted in Hebra's Atlas, and in one more recently 
reported by Galliard,| the disease is generalized. The nails also 
are sometimes invaded, the growth finding its way even into the 
substance of the nail, causing it to become thickened, yellow, 
opaque, and brittle. It is generally observed to occur here in 
connection with tinea favosa capitis, and is accounted for by the 
patient's scratching the head and thus introducing the parasite 
beneath the nail. The disease possesses a peculiar odor, a symp- 
tom by which (when the affection is sufficiently developed) its 
presence may often alone be recognized, being that of mice or of 
stale straw. Usually it is plainly perceptible; in other cases it is 
faint. More or less itching accompanies the disease ; it is gener- 
ally one of the first symptoms noted, and may prove annoying. 

The hairs in tinea favosa of the scalp undergo, as a rule, 
considerable change ; they become lustreless, opaque, dry, brittle, 
and, at times, split longitudinally. In other cases they are less 
extensively invaded. After the disease has existed for some time, 
they loosen and come out or are scratched out, leaving bald patches 
with more or less atrophy of the follicles and sebaceous glands. 
The baldness eventually is in some cases permanent. The course 
of the disease is chronic; unless properly treated, it may last, for 
years or for a lifetime. Even with energetic remedies it is usually 



* See my Atlas of Skin Diseases, Plate O; also Fox's Photographic Illus- 
trations of Skin Diseases, Part IV. 

f Annales de Derm, et de Syph., 2me Ser., t. i. p. 97. 



596 PARASITES. 

an obstinate affection, requiring the prolonged use of parasiticides 
and depilation. Relapses are liable to occur. 

Etiology. — The cause of tinea favosa is found in the presence 
and growth of a vegetable organism, known as the Achorion 
Schonleinii. It Mas discovered by Schonlein, of Berlin, in 1839, 
and was named after him by Remak. The disease is eminently 
contagious. It not infrequently attack's several members of a 
family. I recall an instance (in London) where thirteen members 
of one family, brothers and sisters, were, in the course of years, 
affected; in another case, a mother and two children, constituting 
the whole family, were at the same time suffering from the dis- 
ease. Similar instances are not rare. It docs not, however, attack 
all persons with the same degree of readiness; some, owing to 
peculiarity of skin, state of the general health, or other conditions, 
are more prone to its influence than others. It is commoner in 
children than in adults. It usually attacks children in the first 
place, either de novo or through direct contagion, and is from them 
communicated to adults. It is a disease of the poor, being con- 
fined almost exclusively to the lower classes. It is only rarely 
met with upon the cleanly and well nourished. It is rare in the 
United States. White,* of Boston, out of 5000 consecutiv< 
of skin disease met with in dispensary practice, reports but 17 
. and more than half of these were instances where two or 
three member- of the same family were affected. In Philadelphia 
it is even rarer. In the table of statistics of the American Der- 
matological Association 32 cases out of 1G,8G3 cases of skin dis- 
ease are recorded. In Scotland, on the other hand, the disease is 
not uncommon, Anderson, of Glasgow,f reporting 156 cases out 
of 10,000 consecutive cases of skin disease encountered in dis- 
pensary practice. It is not an infrequent affection among certain 
animals, especially mice, rabbits, cats, dogs, horses, and oxen, from 
whom it is often communicated to man. 

Pathology. — The disease may have its seat either in the hair- 
follicle and hair or upon the surface of the skin ; the follicle and 
hair are the structures usually attacked. It is a local affection, and 
is due solely to the presence and growth of the parasite. The crust 

* Bost. Med. and Surg. Jour., May 18, 1876. 
f Lancet, Xov. 11, 1871. 



TINEA FAVOSA. 



597 



is made up almost entirely of fungus. Upon section it is seen 
with the naked eye to be composed of a porous mass, and to pos- 
sess a pale-yellow or whitish color. Under the microscope it is 
observed to consist of both mycelium and spores in great quantity, 
and in all stages of development. (See Fig. V.) The mycelium 




Fig. V. — Achorion Schoenleinii. (500 Diameters.) 
Showing simple mycelium, receptacles, broken mycelium, and free spores. 

is made up of narrow, apparently flattened tubes, or threads, which 
ramify in all directions without definite arrangement. They aver- 
age from gig'" (.0023 mm.) to jfa'" (.0030 mm.) in diameter,* 
and vary greatly in length. They are straight, curved, bent, or 
crooked, and incline to branch in a forked manner. They have a 
watery, pale-grayish or pale-greenish color. The character of the 
mycelium, which is usually abundant, differs considerably with 
the stage of growth. The filaments may be empty and simple in 
structure, or they may be in a state of fructification and contain 
spores, in which case they are known as "receptacles," "sporo- 



* The measurements of the Achorion Schonleinii, Trichophyton, and Micro- 
sporon Furfur were made with J^th ("Wales's) immersion lens, by Dr. J. G. 
Richardson and myself. 



598 PARASITES. 

phores," or "spore-tubes." These differ from the simple myce- 
lium in being here and there irregularly jointed, and in many 
instances divided into numerous, delicately marked, small parti- 
tions or spaces, containing granules and young spores, the contents 
varying with the stage of development. Often they are divided 
and broken up in such a manner as to have the appearance of 
the links of a chain ; in time these become detached, either singly 
or in variously sized parts, and are found intermingled with the 
spores. 

The spores, or sporules, called also conidia, are irregularly- 
shaped, small bodies, varying considerably in size. They average 
from gi_'" (.0023 mm.) to T ^'" (.0052 mm.) in diameter. They 
are round, rounded, or ovalish, elongated, contracted in the middle, 
or flask-shaped, and have a grayish or pale-greenish, nacreous 
color, refracting light in a marked manner. They assume no dis- 
position to group, although they arc frequently found in aggrega- 
tions. They occur in great numbers, and are present everywhere, 
both in between the mycelium and in other portions of the field, 
being so numerous in some places as to form compact masses. 
Forms of the achorion intermediate between mycelium and spores 
are always present, and Bhow the mode of development. Gran- 
ular matter also exists. 

The parasite may be discovered under the microscope without 
difficulty at all stages of the disease. It is the most abundant 
and luxuriant of the vegetable parasite-. When the affection 
attacks the hairy portions of the surface, the hairs are in all cases 
more or less extensively invaded. It penetrates into the follicles 
and into the root, and develops here in quantity; or it extend- 
itself up the shaft, in which case the hair is more or less disinte- 
grated. This latter course, however, rarely occurs to the same 
extent as in tinea tonsurans. The seat of the fungus is therefore 
different in different cases, as in the case of tinea tonsurans. A- a 
rule, the parasite does not extend itself to the living layers of the 
epidermis, but confines itself to the corneous cell-. In a case ex- 
amined by Unna,* the hair-bulb and the external root-sheath were 
found healthy. According to the same observer, in the epidermis 
the fungus tends to invade the middle cells, between the superficial 

* Viertelj. fur Derm. u. Syph., 1880, Heft 2 und 3. 



TINEA FAVOSA. 599 

and the deep portions of the corneous layer. In the corium the 
condition is partly that of chronic inflammation, and partly that 
of retention. Suppuration, slight or profuse, not infrequently 
takes place beneath the crusts, especially in chronic cases. 

The disease when it attacks the nail may be readily detected in 
a section or in scrapings, presenting the same features as in the 
epidermis or hair, although the growth is seldom so luxuriant as 
in these latter structures, and consequently does not exhibit the 
same tendency to the formation of spores. Mycelium, in various 
stages of development, w T ill usually be found to predominate. 
The achorion Schonleinii is a distinct variety of fungus, and is 
capable of giving rise to one form of disease only, namely, tinea 
favosa. 

Diagnosis. — In the majority of cases no trouble will be expe- 
rienced in the diagnosis. The small, circular, pale- or sulphur- 
yellow, friable crusts, hollowed out in the shape of a cup or 
saucer, and seated upon a slightly inflammatory base, cannot be 
confounded with those of any other disease. At times, however, 
especially in chronic cases, they are broken, their peculiar form 
destroyed, and their surface coated with dirt and other extraneous 
matter, giving them an appearance not unlike the crusts of pus- 
tular eczema. Occasionally, also, the bases of favus crusts sup- 
purate from excessive irritation of the scalp, and pustules may 
appear here and there around the favi, thus obscuring the primary 
disease. The peculiar odor is almost always present where the 
lesions exist in quantity, and usually aifords a ready means of 
diagnosis. A history of contagion may often be obtained. In 
rare cases tinea circinata or tinea tonsurans may coexist with the 
disease. The microscope should always be employed in cases 
of doubt. No difficulty will be experienced in the examination. 
A small fragment of the crust should be placed upon a glass 
slide with a drop of liquor potassse, and covered with a thin 
glass. A power of from two hundred and fifty to five hundred 
diameters is necessary to bring out the features described. 

Treatment. — In the treatment we are influenced by the seat of 
the affection, its extent, and the length of time it has existed. 
Occurring upon the scalp, its favorite locality, it constitutes a 
rebellious disease, and demands thorough handling. The two 
remedies are parasiticides and depilation. Whatever parasiticide 



600 PARASITES. 

is employed, it must be used energetically, and in such a manner 
as to insure the complete destruction of the fungus in the follicle 
as well as upon the surface. In chronic obstinate cases, follicular 
suppuration should be induced, thereby facilitating the expulsion 
of the diseased hairs. The hair is first to be cut as short as pos- 
sible, after which the crusts are to be removed by means of poul- 
tices or applications of almond or olive oil, and soap and hot 
water, as in the case of pustular eczema of the scalp. After they 
have been removed, the scalp in severe cases will show marked 
depressions, areas of atrophy here and there, and more or less 
baldness, or patches of superficial ulceration with suppuration. 
This latter condition may bear a close resemblance to syphilitic 
ulceration. 

Extraction of the hairs, or depilation, is now resorted to. It 
is a most valuable means of treatment; without it, indeed, cure, 
in the case of tinea favosa capitis, becomes a matter of great diffi- 
culty, if not impossible. Before depilation is practised, the part 
to be operated upon should on each occasion be well anointed with 
a simple oil, preferably almond oil. For the extraction of the 
hairs, a forceps with broad blades should be used, thai the hairs 
may be firmly and securely grasped, to prevent their breaking off 
at the level of the skin, an accident which in the case of brittle 
hairs is liable to occur. A few hairs only should be seized at a 
time and pulled out in the line of their long axes. A -mall sur- 
face should be cleared each day. Immediately after the operation, 
one or another of the parasiticidal ointment- or lotions is to be 
well rubbed into the part, and made to penetrate the hair-follicles. 
( Jorrosive sublimate, in the strength of three or four grains to the 
ounce, is one of the best parasiticides. Sulphite of .-odium, one 
drachm to the ounce, as a lotion; sulphurous acid, full strength 
or diluted, as a lotion ; sulphur, a drachm or two to the ounce of 
ointment; yellow sulphate of mercury, half a drachm or more to 
the ounce of ointment; oleate of mercury, ten or twenty per cent, 
strength; and croton oil, arc all valuable remedies. In addition 
to these, the numerous remedies and combinations used in tinea 
tonsurans may be employed. The tarry preparations are also 
serviceable, either alone or in combination with other more active 
remedies, as the mercurials. 

The length of time requisite to effect a cure in tinea favosa 



TINEA TRICHOPHYTINA. 601 

capitis will depend upon its extent and other circumstances; it may 
be stated, however, that in ordinary cases from three to six months 
are necessary. Depilation is to be repeated daily until the new 
hairs assume a healthy state. They should be examined from time 
to time under the microscope. Tinea favosa of the epidermis is to 
be treated, after the removal of the crust, by one of the milder 
above-mentioned ointments, and is seldom rebellious. In treating 
the nail, the parasiticide should be rubbed into and beneath the 
free border of the nail; it should, moreover, be frequently cut and 
scraped. In addition to the means indicated for the cure of the 
disease, certain measures remain to be mentioned. Cleanliness is 
essential. It is, indeed, the first step in the treatment, and with- 
out it but little progress can be made. In some cases, good food, 
fresh air, and the use of tonics, in particular arsenic, will prove of 
benefit. The contagiousness of the disease should always be borne 
in mind. 

Prognosis. — This will depend upon the duration and extent of 
the disease, as well as upon the general condition ; impoverished 
and neglected individuals recover more slowly than those in better 
circumstances. The longer the disease is permitted to continue 
upon the scalp, the more likelihood is there of resulting baldness, 
atrophy, and cicatrix. Tinea favosa of the epidermis is seldom 
obstinate. 

TINEA TRICHOPHYTINA. 

Under this name are included three varieties of disease, known 
as tinea circinata, tinea tonsurans, and tinea sycosis. They may 
be regarded as modifications of one disease, inasmuch as they are 
produced by one cause, namely, the trichophyton fungus. This 
growth when it attacks the general surface of the body gives rise 
to the condition termed tinea circinata; the scalp, hair-follicles, and 
hairs, tinea tonsurans ; the hair-follicles and hairs of the beard, 
tinea sycosis. Although the three affections are due to the same 
cause, they are nevertheless characterized by such distinctive fea- 
tures as to entitle them to separate description. Their treatment, 
moreover, is somewhat different. 



602 PARASITES. 



TINEA CIRCINATA. 

Syn., Herpes Cireinatus; Ringworm of the Body; Fr., Herpes Circine; 
Trichophytie Circinee. 

Tinea circinata is a contagious, vegetable parasitic dis- 
ease, DUE TO THE TRICHOPHYTON, CHARACTERIZED BY ONE OR 
MORE CIRCULAR OR IRREGULARLY-SHAPED, VARIOUSLY SIZED, IN- 
FLAMMATORY, SLIGHTLY VESICULAR OR SQUAMOUS PATCHES, OCCUR- 
RING UPON THE GENERAL SURFACE OF THE BODY. 

Symptoms. — The disease varies greatly in the degree of its de- 
velopment. It may be a trivial affection, as is frequently the case 
in children, or, on the other hand, an extensive, chronic, and ob- 
stinate disease, as seen, for example, about the genito-crnral region 
in the adult. The usual form of the disease may he described as 
follows. It begins as a small, reddish, scaly, rounded, or irregu- 
larly-shaped spot. It may be well or ill defined in outline. As 
the process advances, usually in the course of a few days, the skin 
becomes more inflamed, the patch generally assuming a more dis- 
tinctly circular form, attended either by an increased branny des- 
quamation or by the formation of minute papules, papulo-vesicles. 
or vesicles around the circumference of the lesion. When fully 
developed, the patches are usually circular, and slightly elevated, 
especially about the margins, which are sharply defined againsl 
the healthy skin. They tend to assume a distinctly annular char- 
acter (whence the name ringworm), owing to the disposition which 
the process manifests of disappearing wholly or in part in the 
centre while spreading on the periphery. The patches may be 
the size of a small or large coin ; as usually encountered they are 
about the size of a silver quarter dollar. One, two, or more may 
exist, in which latter case they are apt to coalesce, forming irregu- 
larly-shaped, roundish or ovalish patches, or variously sized semi- 
circles and segments of circles, sometimes assuming the form of 
serpiginous lesions. Ordinarily, however, but two or three are 
present, and these discrete and upon different parts of the body. 
They are pale, bright, or dull pinkish or reddish in color, and are 
usually surmounted with scanty, thin, shreddy, grayish, adherent 
scales, which are more abundant about the margin. In the centre 
of the lesion the surface is generally pale reddish and only slightly 



TINEA CIRCINATA. 603 

scaly. The vesicles, papulovesicles, or even papules, as the case 
may be, when the irritation to the skin happens to be sufficient to 
produce them, exist about the periphery in the form of a ring, 
and are pin-point or pin-head in size. In rare instances, several 
concentric rings may be formed, as in a case reported by Unna.* 

In the case of chronic ringworm, however, the disease assumes 
other and less denned characters. The lesions here are usually 
in the form of single or multiple, disseminated, small, reddish, 
slightly scaly, ill-defined spots, on a level with or but slightly 
raised above the surrounding skin. Not infrequently they are 
the size of a small or large finger-nail, and are irregularly shaped, 
and, as a rule, without line of demarcation. Their manifestation 
is generally insidious, and their development often rapid. Some- 
times they attain considerable size before they are detected. They 
may occur upon any region, and not infrequently occur simulta- 
neously on distant parts of the general surface. In some cases 
they tend to appear and to disappear spontaneously, the disease 
persisting in this manner over a period of years, the patient rarely 
being free of lesions. The fungus in these cases is generally scanty. 

The disease, as a rule, shows no disposition to symmetry, al- 
though it may so happen through contagion in certain regions, as 
the thighs, that both sides of the body are symmetrically affected. 
All parts of the general surface of the body may be attacked ; 
preference, however, is shown for certain regions, especially the 
face, neck, and backs of the hands. The axillae, the inner sur- 
faces of the thighs, the groins, and between the nates, are also 
common seats for the disease in adults; attacking these latter 
localities, it is apt to spread extensively and at times to be re- 
bellious to treatment. 

The disease to which ITebra gave the name " eczema margi- 
natum/' encountered in cavalry-men and others, and in women 
as well as in men, occurring chiefly about the fork of the thighs, 
buttocks, groins, and axillae, is to be viewed as a severe form of 
tinea circinata. When it invades the thighs, its usual seat, it is 
designated tinea circinata cruris. It may, moreover, be 
complicated with true eczema, this disease being usually secon- 
dary. The dermatitis set up is generally marked, as shown by 

* Viertelj. fur Derm. u. Sypli., 1880, p. 165. 



604 PARASITES. 

the redness, desquamation or discharge, pigmentation, and thick- 
ening of the skin. The disease, when fully developed, is char- 
acterized usually by extensive, hand sized or larger, irregularly- 
shaped, inflammatory patches with a sharply defined, marginate, 
more or less raised border. The patches generally coalesce, and 
the disease thus invades the greater part of the inner surface 
of the thighs and buttocks or the groins and mons veneris. It 
inclines to pursue a chronic course, spreading rapidly or slowly, 
and is accompanied by itching, which may be severe. This form 
of tinea circinata varies greatly in its development as scon in dif- 
ferent countries. It manifests itself in a mild type here compared 
with that observed in some other countries. I have encountered 
many eases, but few of which were either of long standing or 
proved rebellious to treatment. Dr. Bulkley's* experience has 
been similar. The late Tilbury Fox,f of London, likewise found 
the inveterate form of the disease rare in his experience. It 
occurs in its most marked form in .Southern Europe, for example 
in Austria, and in tropical countries, but even here frequently 
manifests itself in small patches and as a slight disease.J 

The course of tinea circinata is variable, depending upon the 
region attacked, age and general condition of the patient, climate, 
and other circumstances. It may vn\) a brief course, lasting a, 
lew weeks, or, on the other hand, it may continue for months or 
years. Occasionally it exhibits a remarkable degree of obstinacy, 
showing itself repeatedly in the same region in the form of re- 
lapse-, or manifesting itself from time t<» time in new localities. 
In most of the cases of this kind that have been under my ob- 
servation, some of them for a period of years, the lesions have 
been remarkably superficial, small, and disseminated, appearing 
and disappearing in the most arbitrary manner, in children it i.-, 
usually very amenable to treatment, and not infrequently pursues 
a course terminating in spontaneous recovery. Jn hot climates it 
is much more intractable than in temperate climates. Jt may 
coexist with tinea tonsurans. § 

* Chicago Med, Jour, and Exam., Nov. 1877. 
f Arch, of Derm., Oct. 1878. 

X See "On Certain Endemic Skin and Other Diseases of India and Hot 
Climates generally," by Drs. Tilbury Fox and T. Farquhar, London, 1876. 
\ See Plate E E in my Atlas of Skin Diseases. 



TINEA CIRCINATA. 605 

The trichophyton occasionally tattacks the nails, causing the 
condition known as tinea teichophytina unguium. The 
nails become opaque, whitish, thickened, and soft or brittle, es- 
pecially along their free border. The diagnosis is readily estab- 
lished under the microscope. It rarely happens that more than 
two or three nails are affected.* The disease pursues a chronic 
course, and is very difficult to cure. 

Etiology. — It is caused by the presence of the trichophyton, a 
discovery made by Bazin in 1854.f It is the same growth which 
produces the forms of disease known as tinea tonsurans and tinea 
sycosis. It, however, shows itself in a somewhat different stage 
of development, seldom arriving at the luxuriant state attained 
in either of the just-mentioned varieties of disease. ' The affection 
is highly contagious, and is frequently communicated from one 
member of a family to another. The chronic forms, as seen some- 
times in tinea circinata cruris, are less contagious. Tilbury Fox| 
describes an instance where seven persons, adults, and members of 
one household, contracted the disease one from the other. It may 
also be contracted from cows, oxen, and horses, the trichophyton 
being known to attack these animals. Megnin§ mentions the 
instance of fifteen soldiers becoming simultaneously affected with 
tinea circinata of the face and neck from sleeping on horse-blank- 
ets which had been used on horses that had the disease. In these 
cases the disease is usually of a much severer tyj)e than when con- 
tracted from man. It is much more common in children than in 
adults, attacking infants as well as older children. Sometimes it 
occurs within a few days after birth. It has been observed as early 
as within six hours after birth, as in the case reported by Lynch. || 
It occurs more frequently in some countries than in others. Ander- 
son,*[[ of Glasgow, reports 54 cases only out of 10,000 consecutive 
cases of skin disease encountered in dispensary practice ; on the 
other hand, White,** of Boston, records 100 cases out of 5000 
consecutive cases of skin disease met with at the out-door depart- 

* See an article by the author in Med. and Surg. Keporter, Aug. 3, 1878. 

f Considerations sur la Mentagre et les Teignes de la Face. Paris, 1854. 

% Arch, of Derm., Oct. 1878. 

I Le Progres Med., Jan. 1, 1881. 

|| Med. Press and Circ, March 22, 1876. \ Lancet, Nov. 11, 1871. 

** Bost. Med. and Surg. Jour., May 18, 1876. 



606 PARASITES. 

ment of the Massachusetts General Hospital. In ray opinion, all 
individuals are not equally susceptible to the ravages of the para- 
site. A certain condition of the skin, I have long held, is requi- 
site for its development and growth. It will not take firm root 
upon every skin. The peculiar nature of the condition essential 
for its growth is unknown ; in some cases, however, especially in 
adults, the disease is dependent upon a depreciation in the general 
tone of the system, consequent, it may be, upon chronic constitu- 
tional disease, as phthisis, or upon some temporary systemic de- 
rangement. I entirely agree with the late Dr. Tilbury Fox when 
he says, "something more than mere contact is needed in the adult 
to insure contagion." In children it occurs much more frequently 
among the weakly, pale, spare, and poorly nourished than among 
the stout and hearty. In the adult, however, this difference is not 
so marked. 

Pathology. — The fungus alighting upon the surface finds its way 
into the epidermis, which it permeates in all directions. At first 
hyperemia is produced, which is soon followed by superficial in- 
flammation, with or without slight papulation or vesiculation, and 
desquamation. The seal of the parasite is in the epidermis, es- 
pecially the corneous layer, and in this tissue only, although the 
irritation occasioned affects the true skin to such an extent as to 
give rise often to marked inflammation. (See Tinea Tonsurans.) 
As already stated, vesiculation may or may not be present ; more 
or less desquamation, however, is always at hand, and is especially 
noticeable about the margin of the patch. As a rule, it is not 
abundant, the scales being thin, shreddy, and shrivelled. 

Under the microscope the fungus is seen embedded in the epi- 
dermic cells in the form chiefly of mycelium, the spores existing 
usually scantily. (Sic Fig. VI.) The mycelium consists of long, 
slender, delicate, sharply contoured, pale-grayish, ribbon-like for- 
mations, or threads, containing spores and granules. It is jointed 
at irregular intervals, and is remarkable for its length, a single 
thread not infrequently extending itself over the field, sending off 
branches here and there in all directions. It varies from 1 2 1 - - /// 
(.0018 mm.) to -sot'" (.0026 mm.) in diameter. It may pursue a 
straight, curved, or crooked course; it is, moreover, usually forked. 
Where the fungus is abundant, the threads cross and recross one 
another in such a manner as to form an irregular net-work. 



TINEA CIRCINATA. 



607 



The spores are small, round or rounded, highly refractive, 
persistent bodies, appearing of a grayish or pale-greenish color. 
They do not assume the manifold forms met with in the achorion 
Schonleinii or in the microsporon furfur. They vary from xoVo'" 




Tig. VI. — Trichophyton, as found in Tinea. Circinata. (500 Diameters.) 
Showing mycelium and spores. 

(.0021 mm.) to -g-oV" (.0035 mm.). They are met with singly or 
in the form of chains of two, three, or more, and may be isolated 
or joined to the mycelium. The fungus, as a rule, does not grow 
luxuriantly in tinea circinata as the affection is encountered in this 
country. Often it is scanty, but it may always be found in the 
early stage of the affection. Where the disease is of long standing, 
or is complicated with marked chronic inflammation, it is not in- 
frequently difficult of detection. In tropical countries, on the other 
hand, it is usually abundant. The botanical relations of the tri- 
chophyton have been studied by Dr. I. E. Atkinson, of Baltimore.* 
His experiments go to show that the fungus belongs to the mucors, 
and is probably mucor mucedo. 



* New York Med. Jour., Dec. 1878. 



608 PARASITES. 

Diagnosis. — This may be determined either by the clinical fea- 
tures of the disease or by means of the microscope. Where the 
fungus exists in profusion, no trouble is experienced in demon- 
strating it under the microscope. The examination is best made 
in the following manner. A few of the scales may be scraped with 
a blunt knife-blade from the suspected patch and placed upon a 
glass slide containing a drop of liquor potassre, over which is laid 
a thin glass cover. The cover should be pressed down and the 
epidermic mass flattened out. Permitting the specimen to remain 
for a few minutes, it may be viewed with a power of from two 
hundred and fifty to five hundred diameters. The fungus will 
in most cases be detected here and there, having at first a faint 
outline, but becoming more distinct as the specimen stands. It 
need scarcely be added that it is of importance that the slide and 
cover be scrupulously clean and free of shreds of lint and other 
extraneous matter. The mycelium is liable to be confounded with 
fibrils of wool and cotton, which often become involved with the 
specimen, but more especially with the margins of epidermic cells, 
which incline to overlap one another in a manner which gives rise 
to an appearance resembling short mycelium. The outline of 
mycelium, however, is always distinctly defined, it- walls showing 
parallel lines; the threads usually stretch for a considerable dis- 
tance over the field, and contain spores and granular matter. The 
spores are to lie distinguished from extraneous fatty particles, as 
the fat of ointments which may have been used in the treatment ; 
from sebaceous matter; from fat globules in fattily degenerated 
cells, as in seborrhea ; from the nuclei of cells; from pus and 
other cells; and from granular matter of one kind or another. 
Where fatty matter prevails, the specimen may be advantageously 
submitted to a few drops of ether. 

Tinea circinata may be mistaken for eczema. It may resemble 
the erythematous, papular, vesicular, or scpiamous varieties, espe- 
cially the latter. Its tendency to a circular and often annular 
form; its well-defined margin; its generally slight and shreddy 
desquamation; together with its course and history, will, however, 
usually render the diagnosis easy. The small, irregularly-shaped, 
slightly scaly spots, which incline to come and go from time to 
time, are much more difficult of diagnosis. The parasitic nature 
of spots of this character should always be suspected. The more 



TINEA CIRCINATA. 609 

aggravated varieties of the disease, as encountered about the 
thighs and contiguous parts, may also resemble eczema closely, 
and may indeed, as stated, in some cases be complicated with 
eczema. The marginate character of the patches in these cases 
points in itself strongly to there being a parasitic element present. 
The microscope should in all such cases be employed. Errors in 
diagnosis may often thus be avoided. 

Tinea circinata bears a close resemblance to seborrhoea of the 
chest and back. Patches of seborrhoea occurring in these regions 
often take on a circular and annular form and are accompanied 
with desquamation very similar to that of tinea circinata. Ring- 
worm, however, may be known by its inflammatory nature, by 
its course, and by the absence of enlarged follicles and a greasy 
surface. It may also be mistaken for psoriasis, especially when 
the patch of psoriasis happens to assume the circinate form, as 
often occurs when the disease is about disappearing. The presence 
of psoriatic patches on other parts of the body, as well as the his- 
tory of the case, will aid in the diagnosis. The microscope here, 
as in all doubtful cases, will decide the question. 

Tinea circinata in its ordinary forms can scarcely be confounded 
with any of the manifestations of syphilis. When it is of long 
standing, and the skin chronically inflamed, as sometimes occurs 
about the thighs, it may be mistaken for the serpiginous tubercular 
syphiloderm. The microscope, the existence of other symptoms 
of syphilis, and the history will assist in arriving at a conclusion. 
It may be known from tinea favosa of the epidermis by the 
absence of the characteristic yellowish crust of this disease; the 
patch of tinea favosa, moreover, is usually smaller and less dis- 
tinctly circinate than that of ringworm. The microscope will 
determine the diagnosis, for the two varieties of fungi are quite 
different. 

Treatment. — As a rule, local treatment alone is required. In 
certain cases, however, particularly in adults, where the disease 
continues persistently in spite of parasiticides, internal remedies of 
a tonic nature should be generously prescribed. The preparations 
of iron, arsenic, quinine, cod-liver oil, and the mineral acids, will 
all be found serviceable. In the majority of cases, however, as 
the disease exists in this country, the fungus has but a feeble hold 
on the skin, and is easily destroyed by any of the parasiticides. 



610 PARASITES. 

In the choice of a remedy the physician should be guided by the 
age of the patient, the extent aud seat of the disease, whether 
localized or diffused, aud the state of the skin as to the amount of 
inflammation, thickening, and irritability. In children the milder 
applications are usually sufficient to remove the disease. Wash- 
ing the patch with soft soap aud water aud afterwards applying 
an ointment of ammoniated mercury, half a drachm to the ounce, 
will often suffice. Ointment of the nitrate of mercury, two or 
four drachms to the ounce of simple ointment; oleate of mer- 
cury, from five to fifteen per cent, strength; or the yellow sulphate 
of mercury, from fifteen to thirty grains to the ounce; may also 
be used. Corrosive sublimate is an excellent remedy, used as a 
lotion with water or alcohol in the strength of from two to four 
grains to the ounce. Carbolic acid, thymol, acetic acid, boracic 
acid, tincture of iodine, ethylate of sodium, and cantharidal collo- 
dion, painted over the patches, are also useful. Sulphurous add. 
full strength or weakened, one part to two or four, in the form 
of a lotion; hyposulphite and sulphite of sodium, a drachm to 
the ounce, either as a lotion or as an ointment; are very service- 
able, and are, moreover, safe remedies. An undoubted and effi- 
cient parasiticide, but one which should always be used with care, 
is goa-powder, in the form of an ointment, from ten t<> forty 
grains to the ounce. The remedy is highly esteemed in Eastern 
countries. Chrysophanic acid (chrysarobin) and pyrogallic add, 
from five to twenty grains to the ounce, may also be used.* When 
the patches are in a state of irritation, as may occur from the too 
frequent use of strong parasiticides, mild tar ointment, half a 
drachm or a drachm to the ounce, or carbolic acid ointment or 
lotion, ten or fifteen grains to the ounce, may be employed with 
benefit. In obstinate tinea circinata cruris, the following, recom- 
mended by Tilbury Fox, may be employed : 

R Creasoti, t^xx ; 

Olei Cadini, f^iii ; 

Sulphuris Sublimati, giii ; 

Potassii Bicarbonatis, gi ; 

Adipis, si. 
M. Ft. ungt. 



For the manner of using these remedies the reader is referred to p 320. 



TINEA CIRCINATA. 611 

Wilkinson's ointment as modified by Hebra (see Scabies) will also 
be found serviceable in these cases. Sulphurous acid, pyrogallic 
acid ointment, five or ten per cent, strength, and goa-powder oint- 
ment, of a similar strength, will likewise prove valuable here. 
Sulphur or mild mercurial vapor baths may in some cases be re- 
sorted to with advantage. Whatever the remedy used, care should 
be taken that the skin be not too much irritated; it should be 
remembered that the disease has a superficial seat, and is therefore, 
as a rule, easily reached. Ointments should be well rubbed into 
the affected part twice or thrice daily, special attention being di- 
rected to the borders of the patches. If weak lotions be used, as, 
for example, boracic acid or sulphurous acid lotion, they should 
be applied for ten or fifteen minutes on each occasion. 

Prognosis. — It is not easy to predict the course of the disease. 
"While the majority of cases yield readily to treatment, instances 
not infrequently present themselves, especially in adults, where the 
affection persists, usually in the form of relapses, for a long period. 
In children it may terminate spontaneously, or be cured usually 
with the aid of one or another of the simpler remedies. In some 
cases, however, even in children the disease is rebellious, the ten- 
dency to relapse being the difficulty. Tinea circinata of the thighs 
and neighboring parts is the most obstinate local variety. 

Tinea Imbricata.— Under this name Dr. Manson, of Amoy, 
China, describes* a disease which he regards as essentially distinct 
from tinea circinata. It occurs chiefly about the Straits of Ma- 
lacca and in the islands of the Malayan Archipelago. The term 
imbricata expresses the peculiar form of desquamation displayed. 
Starting from the point of inoculation, the epidermis becomes 
undermined, and finally detached in long flakes about one-eighth 
of an inch in breadth, the free edge of the flakes being directed 
towards the centre or point of inoculation, the convexity being 
firmly attached. If the hand be passed over the surface from 
the circumference towards the centre of the rings in the form of 
which the scales are arranged, the latter are smoothed down ; if 
in the reverse direction, they are raised up and stand out prom- 



* Medical Reports of the Imperial Chinese Maritime Customs, 16th issue, 
Shanghai, 1879. 



612 PAEASITES. 

inently, defining the wavy "watered" outline of the rings very 
distinctly. The formation of concentric circles is as follows. As 
soon as the primary ring has attained a diameter of about half 
an inch, a brownish patch is again seen to be forming at its centre. 
This, in its turn, cracks the young epidermis over it, and a second 
ring is formed inside the first, which it follows in its extension. 
This process may go on until the entire surface of the body is 
covered ; and this is a point of difference between tinea imbricata 
and tinea circinata. Another difference is the enormous abun- 
dance of fungous elements iu tinea imbricata and their scantiness 
in tinea circinata. The conidia of the fungus in tinea imbricata, 
moreover, are more oval than those of tinea circinata, while the 
mycelial threads are characterized by the absence of swellings and 
constrictions and other irregularities of outline which exist in the 
latter. Manson considers this affection identical with "Tokelau 
ringworm," a variety of disease described by Fox and Farquhar.* 
Manson has shown by inoculation experiments on the same indi- 
vidual that the fungus of tinea imbricata always produces tinea 
imbricata, and that of tinea circinata, tinea circinata. 

TINEA TONSURANS. 

Syn., Herpes Tonsurans ; Triehonosis Furfuracea; Ringworm of the Scalp; 
Porrigo Furfurans; Tinea Tondens; Germ., Scherende Flechtej Fr., Herpes 
Tonsurant; Teigne Tondante j Teigne Tonsurante. 

Tinea tonsurans is a contagious, vegetable parasitic affec- 
tion OF THE SCALP. DUE TO THE TRICHOPHYTON, CHARACTERIZES BY 
CIRCULAR OR IRREGULARLY-SHAPED, VARIOUSLY SIZED, SCALY, MORE 
OR LESS BALD PATCHES, SHOWING THE HAIR TO BE DISEASED AND 
USUALLY BROKEN OFF CLOSE TO THE SCALP. 

Symptoms. — It usually begins in the form of a small, rounded, 
or irregularly-shaped, erythematous, scaly patch, which soon be- 
comes the seat either of a ring of pin-head sized, ill-defined vesi- 
cles or pustules, ephemeral iu character, and which terminate in 
desquamation, or of furfuraceous scales. It spreads rapidly, and 
in a short time in typical cases attains its characteristic features, 
when it consists of one or more circular, circumscribed patches, 

* On Certain Endemic Skin and other Diseases of India and Hot Climates 
generally, pp. 59, 2-i'j. London, 1876. 



TINEA TONSUKANS. ' 613 

varying in size from a small to a large coin, of a reddish, grayish, 
greenish-yellow, or bluish color, covered with fine or coarse scales, 
with the hairs broken off close to the scalp. The color varies 
with the complexion of the subject. In dark-haired children it is 
of a light or dark bluish-gray, leaden, or slate color. The scalp is 
more or less raised, and the follicles, as a rule, are prominent, giv- 
ing the surface a goose-skin or " plucked fowl" appearance, which 
is characteristic of the disease, and which is most marked after 
the disease has existed for some time and the hairs have fallen out. 
The hairs are uniformly or more often irregularly short, rarely 
more than one or two lines in height, and are thickened, and 
twisted or bent. Their free extremities present a ragged, uneven, 
stubble-like or nibbled look, as though they had been broken off 
or had been cut with blunt scissors. They lack their normal 
lustre, are dull and lifeless, opaque in color, and upon extraction 
are found to be dry, harsh, and generally brittle. They are seated 
loosely ,in their follicles, but are liable to break off close to the 
scalp in an attempt to extract them. As the disease progresses, 
they incline to rupture, owing to the excessive infiltration of the 
fungus, and drop out of their own accord. As a result of the 
loss of hair, baldness, more or less complete, exists, which, how- 
ever, is temporary, the growth of hair returning sooner or later. 
When the disease is fully developed, the scales are usually com- 
minuted and are present in the form of a fine or coarse, adherent, 
grayish, powdery product. The patches vary in size from a 
small to a large coin. They are seldom larger than a silver dollar, 
although two or more upon the same region not infrequently run 
together, thus forming sometimes more extensive areas of disease. 
Where several patches have coalesced, palm or even hand sized 
areas may result. They may have their seat upon any part of 
the scalp, although they show preference for the vertex and the 
parietal region. More or less itching is generally experienced ; 
sometimes it is one of the first symptoms noted. In other cases 
there is little or no itching. The disease may spread on to the 
side of the face, in which case it becomes tinea circinata. The 
two conditions may occur simultaneously or either may precede 
the other.* Permitted to run 

* See my Atlas of Skin Diseases, Plate E E. 



614 * PARASITES. 

surans may continue indefinitely, as in the case of the other vege- 
table parasitic diseases; on the other hand, it may terminate in 
spontaneous recovery. 

I have thus described the usual form of the disease. Unusual 
forms are also encountered, as, for example, where the lesions are 
disseminated and superficial, the process assuming somewhat the 
character of tinea circinata of the scalp. The lesions here resem- 
ble those of eczema or of seborrhcea.* The hairs in places may 
remain in situ and be apparently unaffected, while on other por- 
tions of the scalp short stumpy hairs may be seen. Traction upon 
the long hairs generally proves them to be loosely seated. Some- 
times, however, they are securely lodged. These forms of the 
disease occur chiefly in light-haired subjects and among the poorly 
nourished and weakly. 

Other variations, or deviations from the typical process, are also 
met with, and they are important from a diagnostic point of view. 
In the early stage of the disease the lesions may consist merely of 
a slight scaly patch, with or without hyperemia or inflammation, 
the hairs being usually long and firmly seated. It is not until 
later that they begin to break and to appear as short stumpy hairs. 
In this stage the disease may also readily lie mistaken for eczema 
or seborrhcea, especially the latter. Another variety is character- 
ized by discrete or grouped small pustules, which tend to crust 
and so to form 'crusted patches. This form i- seen usually late 
in the course of the disease, and is liable to be mi-taken for pus- 
tular eczema. 

Chronic ringworm remains to be referred to. Here the disease 
has existed perhaps six months or one or two years, and presents 
features different from those described. The lesions consist of 
small or large, discrete or confluent, disseminated or localized, for 
the most part irregularly-sized, scaly patches. The scales may be 
-canty or abundant, and are generally noted to be heaped up into 
minute conical elevations about the hair-follicles, giving the sur- 
face the plucked-fowl appearance. The hairs are usually short, 
and the patch consequently partly bald, or they may be broken 
off close on a line with the scalp, giving the patch a punctate or 



* See notes of eases by the author in Med. and Surg. Eeporter, Aug. 3, 
1878. 



TINEA TONSUEANS. ' 615 

clotted appearance. This latter event occurs especially in dark- 
haired subjects. In blonds the hair is seldom broken off so short, 
while at times it may even be long, in which case the hair falls 
insidiously. Different lengths of hair are generally present. In 
chronic ringworm there is rarely any marked inflammation. The. 
disease may be confined to a small area or may involve the greater 
part of the scalp, in the form of numerous small and large finger- 
nail sized lesions, with usually one or two larger areas. 

Etiology. — The cause of the affection is found in the presence 
and growth of the trichophyton, the same fungus which gives rise 
to tinea circinata. The disease is a common one, and is met with 
universally. It is an affection of childhood, being very rarely 
encountered in adult age, and seldom after puberty. Tilbury 
Fox * speaks of meeting with it in the adult, but I have never 
seen it in persons over sixteen or seventeen years of age. On the 
other hand, it is rare in infancy. It is highly contagious, and may 
readily be communicated from one child to another by means of 
wearing-apparel, caps, combs and brushes, towels, and bed-linen. 
Its contagious properties are frequently manifested in schools and 
children's asylums, where a number of inmates may become af- 
fected at the same time. It is liable to attack all classes, the rich 
as well as the poor, but especially those who are poorly nourished, 
in ill health, or debilitated. It is often contracted from tinea 
circinata existing upon the mother or attendant. 

Pathology. — Under this head are to be considered the changes 
which take place in the hair, hair-follicle, and epidermis, as well 
as the peculiarities of the fungus. The parasite was discovered by 
Gruby in 1844, and fully described by Malmsten in 1846, and 
named by him "trichophyton tonsurans." It invades the hair, 
hair-follicle, and epidermis. The hair, however, suffers most se- 
verely, becoming in a short time filled with the growth, to such 
an extent usually as to cause its disintegration and destruction. 
The follicle is also attacked, becoming distended and prominently 
raised. The fungus is the same as that of tinea circinata, and has 
been considered in connection with that disease. It exists here in 
a somewhat different stage of development. It is found in a state 
of exuberant growth, spores existing in great profusion. As seen 

* Eingworm and its Management. London, 1878. 



616 



PARASITES. 



under the microscope, the broken hairs are invaded throughout 
their length with spores and jointed mycelium, the former mark- 
edly predominating. Often little or no mycelium is found. The 
spores are very numerous, and exist around the outside of the bulb 
and root, as well as inside the hair-substance, where they take more 




















Fig. VII.— Trichophyton, as FOUND in Tinea Tonsurans. (300 Diameters.) 
Short, brokcn-off hair of scalp, invaded with free spores and chains of spores. 



or less complete possession of the structure. They are found in 
rows running parallel to the filaments of the hair or in irregularly 
disposed masses. The bulb and root are usually so extensively 
invaded as to be literally crammed with spores, appearing as a 
solid mass resembling fish-roe. The hair is distended or ruptured 
here and there along its shaft, the filaments protruding at these 
points, giving its exterior an uneven or ragged surface. It is at 
times split up longitudinally, its component parts separated and 



TINEA TONSURANS.. 617 

barely holding together. The free end of the shaft, at the point 
of fracture just beyond the level of the scalp, generally possesses 
a jagged, bristly, stubble-like extremity, consisting of broken fila- 
ments, between which spores may be found. (See Fig. VII.) The 
furfuraceous scales scraped from the surface of the patch may also 
contain fungus; but the disease attacks the hair to the comparative 
exclusion of the epidermis. The amount of irritation to the skin 
varies ; frequently it is slight, giving rise merely to desquamation 
or ephemeral vesicles ; in other cases it is severe, causing oedema 
and inflammatory symptoms with fluid exudation, as occurs in the 
variety of the disease termed tinea kerion, to be described. 

The anatomical seat of the fungus varies in different cases. It 
may be seated only in the corneous layer of the epidermis and hair- 
shaft, or it may extend even to the subcutaneous tissue. The con- 
dition of the skin has been examined microscopically by Taylor,* 
who states that the fungus invades the substance of the hair as far 
down as the bulb, but that it never advances to any distance into 
this structure, nor, in fact, attacks living tissue, as the hair-papilla 
or root-sheaths. These observations are confirmatory of those of 
Thin,f whose studies were made upon the horse.. Robinson,! on 
the other hand, found that both spores and mycelium, in varying 
quantity, isolated, grouped, or arranged in rows, were present in 
the mucous layer of the epidermis, and even in the coriuni. 

Diagnosis. — In most cases the diagnosis is easy. The presence 
of numerous follicles deprived of their hairs should always lead 
one to suspect the disease. The existence of stumpy hairs is even 
more suspicious. Blackish dots, apertures of follicles containing 
broken-off hairs, disseminated over a partly bald surface, or in 
the form of scattered small areas, should also be viewed with sus- 
picion. There are several diseases with which it may be confounded. 
Squamous eczema is frequently met with about the scalp assuming 
the form of patches which may resemble tinea tonsurans. The 
histories of the affections are different, and will usually suffice to 
distinguish them. In eczema there is no history of contagion, 
a point which can frequently be established in tinea tonsurans. 
Squamous eczema is usually a chronic disease; tinea tonsurans, on 



* Lancet, Nov. 16, 1878. f Ibid., March 30, 1878. 

% New York Med. Jour., March, 1881. 



618 PARASITES. 

the other hand, generally pursues a more rapid course and spreads 
progressively. The patches of eczema are not apt to be sharply 
defined or circular. The hairs in eczema remain firmly implanted 
in the scalp; in tinea tonsurans they are loose, and can be plucked 
out without causing pain. In eczema, moreover, the characteristic, 
thickened, twisted, brittle, or broken-off hairs, as well as the pecu- 
liar color of the patch, covered with furfuraceous scales, are absent. 
In doubtful cases the microscope will always reveal the presence 
of the parasite. Itching is a more prominent symptom in eczema 
than in tinea tonsurans. In some cases eczema may supervene 
upon or be complicated with the disease under consideration ; but 
this occurrence is rare. In ringworm of long standing or in cases 
that have been treated, the diagnosis is much more difficult, and 
the microscope should always be employed. 

Tinea tonsurans, especially the disseminated form, may very 
readily be mistaken for scborrheea. The microscope here offers 
the easiest and sometimes the only solution of the question. Pso- 
riasis may also present an appearance not unlike tinea tonsurans; 
but the healthy state (if the hairs, and the quantity and character 
of the scales, as well a- its course, will serve to distinguish it. 
Tinea favosa in its earliest stage, before the formation of the crust, 
may also be mistaken for the disease; in a short time, however, 
the characteristic crust shows itself, and no further difficulty 
will be experienced. Alopecia areata may also be confounded 
with tinea tonsurans, a mi-take of not infrequent occurrence. In 
typical examples of alopecia areata, the absence of all hair from 
the patch, and the whitish, smooth, polished surface, will be suf- 
ficient to establish the diagnosis. In other cases, however, where 
the characteristic symptoms are wanting, recourse must be had to 
the microscope, which will at once determine the question. 

The microscopic examination of the hair offers no difficulty. 
The parasite is readily detected. One or two of the short, stumpy 
hairs should be placed upon a slide with a drop of liquor pi 
and permitted to stand a few minutes, when, under a power of 
two hundred and fifty diameters, the fungus as well as the lesions 
of the hair will be visible. (See Tinea Circinata.) According to 
Duckworth,* the action of chloroform upon patches of tinea ton- 

* Brit. Med. Jour., Nov. 1, 1873. 



TINEA TONSURANS. 619 

surans is specific, and serves as a ready test for this disease. If 
a few drops be poured upon a patch and allowed to evaporate, 
a peculiar appearance is observed in the affected hairs and upon 
the skin at the openings of their follicles; they become whitish 
or light yellow in color and remain so, the part looking as if 
sprinkled with a film of sulphur powder. Chloroform has no 
such effect upon healthy hair. The same change has been noted 
in connection with tinea circinata, tinea versicolor, and tinea 
favosa of the epidermis,* the patches assuming a whitish, pow- 
dery appearance. 

Treatment. — It will be borne in mind that the same fungus ex- 
ists here as in tinea circinata, although in a more luxuriant state 
of growth ; the disease, consequently, is amenable to the remedies 
referred to in speaking of this disease. Tinea tonsurans, how- 
ever, is very much more difficult to cure than tinea circinata, and 
usually demands active treatment. The scalp, as a rule, tolerates 
strong remedies. The destruction of the parasite, which has its 
seat in the hair-structure as well as in the follicle, is best accom- 
plished by extraction of the hairs, together with the use of suitable 
parasiticides. As a rule, external remedies are all-sufficient to 
bring about a cure ; in some cases, however, when the affection is 
of a severe type and is rebellious to local treatment, constitutional 
remedies, as iron, arsenic, and cod-liver oil, may be employed with 
advantage. Strict attention to cleanliness is important, not only 
with the view of hastening the cure, but also in order to prevent 
contagion. The patient should be provided with special wearing- 
apparel, combs, brushes, towels, and bed-linen. 

The loose hairs about the edges of the patches, and the broken- 
off hairs over the surface, are first to be extracted. They are best 
depilated by means of a small, broad-bladed, short forceps, a few 
hairs only being seized at a time. A portion of the diseased hairs 
may thus be removed each day until the surface has been cleared. 
After each depilation a parasiticide is to be applied, in the form 
of an ointment, oil, or lotion, as may seem indicated. The choice 
of a remedy, and the strength, will depend upon the case. If the 
hairs are thoroughly invaded with the fungus, as demonstrated 
by the microscope, strong remedies causing follicular suppuration 

* St. Bartholomew's Hospital Reports, vol. ix. 



620 PARASITES. 

are demanded ; if, on the other hand, the disease is superficial, 
some of the milder remedies may first be tried. Among these, 
sulphurous acid, full strength ; sulphuret of potassium, thirty 
grains or a drachm to the ounce; hyposulphite of sodium, one 
or two drachms to the ounce; and boracic acid, may be men- 
tioned as the most useful. In light-haired subjects, sulphurous 
acid, followed by sulphur ointment, frequently proves valuable. 
Sulphite of sodium, a drachm or two to the ounce, may be em- 
ployed advantageously as an ointment. Besnier speaks well of 
boracic acid, fifteen grains ; sublimed sulphur, fifteen grains; and 
vaseline, one ounce. The late Mr. Startin esteemed the following 
for light cases: 

R Sulphuris Sublimati. gss : 

Hydrargyri Ammoniati, gr. x ; 

Hydrargyi Sulphureti Nigri, gr. x ; 
31i.<ce et adde 

Olei Olivje, f^ii ; 

Creasoti, gtt. iv ; 

Adipis, ,~vi. 
M. Ft. ungt. 

An ointment composed of equal parts of carbolic acid, ointment 
of the nitrate of mercury, and sulphur ointment, is spoken of by 
Alder Smith* a- being useful in recent cases where considerable 
surface is involved. The same ointment with lc~^ carbolic acid 
will be found better adapted to the majority of cases. The milder 
parasiticides should be used freely; in the case of lotions they 
should be applied often, and for ten or fifteen minutes at a time; 
ointments should be slowly and thoroughly rubbed into the patches, 
and also around their edges. 

Corrosive sublimate, as an ointment, from two to five grains 
to the ounce, or as a lotion, from two to live grains to the ounce 
of water or alcohol, sometimes answers well. It has also the ad- 
vantages of being cleanly, of having no unpleasant odor, and of 
not discoloring the skin. Ammoniated mercury and red oxide of 
mercury, from thirty to sixty grains to the ounce, and ointment 
of the nitrate of mercury, will be found useful in the various 
stages of ordinary cases. Where the disease is disseminated and 
superficial, from one to three drachms of carbolic acid to the 

* Lancet, vol. i., 1880. 



TINEA TONSURANS. 621 

ounce of glycerine will frequently be of service, either alone or 
in connection with other remedies. Thymol may also be used. 
Malcolm Morris speaks well of a mixture of thymol, half a 
drachm ; chloroform, two drachms ; olive oil, six drachms. In 
the more chronic forms of the disease, oleate of mercury, ten or 
twenty per cent, strength, will be found valuable. Tincture of 
iodine, the usual or double strength, also proves serviceable. A 
preparation much used in London, known as Coster's paste, is 
the following : 

R Iodini, gii ; 

Olei Picis, fgi. 
Misce et solve. 
]ST.B. The iodine and oil of tar should be gradually 
and slowly mixed. 

It is painted upon the patches with a brush and allowed to 
remain on until the crust is cast off, in the course of five or six 
days, when it may be reapplied. A few applications often suffice. 
Equal parts of tar ointment and sulphur ointment, or sulphur 
ointment alone, are both useful. 

For chronic cases, painting the patches with glacial acetic acid 
or cantharidal collodion once a week or oftener, and making use 
of one of the milder parasiticides, as sulphurous acid or sulphur 
ointment, in the mean time, is a good method of treatment. 
Where the disease is confined to small areas and proves rebel- 
lious, the artificial production of tinea kerion by means of the 
cautious application of croton oil will be found valuable. The 
remedy is a severe but most useful one. Frequently it will cure 
where all other remedies have failed. It may be used pure, care 
being taken not to allow it to run over the edges of the patch, 
or weakened with two or four parts of olive oil. I usually apply 
the pure oil, employing it at first sparingly. It is apt to involve 
the skin considerably beyond the line of application, a practical 
point which should be remembered. The part should subse- 
quently be poulticed and then depilated. The application is to 
be repeated as may be necessary to set up the requisite amount 
of follicular suppuration. The oil should be applied in every 
instance by the physician himself. 

Prognosis. — This must depend upon the length of time the 
affection has continued, the number of patches, and also the state 



622 PARASITES. 

of the general health. Some cases yield readily ; others are ex- 
tremely obstinate, months often being necessary to effect a cure. 
In children who are poorly nourished it is always more re- 
bellious than in the well cared-for. In asylums and schools it 
is usually much more difficult to control than in isolated cases. 
Spontaneous cure may take place, although, as a rule, the disease 
when left to itself tends to run on indefinitely. Relapses are ex- 
tremely liable to occur, and should always be guarded against. 
The case should be inspected from time to time for at least a 
month after the disease has been pronounced cured. 

Tinea Keiuox. — Under this name is to be described a peculiar 
form of tinea tonsurans occasionally met with. It was originally 
described by Celsus; more recently by Wilson, Tilbury Fox, and 
others. It may be viewed as an inflammatory and suppurative form 
of tinea tonsurans, characterized by oedema, inflammation, and the 
exudation of a viscid, glutinous, yellowish secretion from the open- 
ings of the hair-follicles. The condition is analogous to that fre- 
quently seen in tinea sycosis. It may occur with the usual form 
of tinea tonsurans or alone. It begins generally as ordinary tinea 
tonsurans, and is followed in a short time by tumefaction and deep- 
seated subacute inflammation. When fully developed, the patches 
are yellowish, reddish, or purplish in color, and are more or less 
raised, nedematous, and boggy. They are uneven and honeycomb- 
like (whence the name kerion), and studded with yellowish, sup- 
purative points, or, later, with small cavities, or foramina, the 
openings of the distended hair-follicles deprived of their hairs, 
which discharge a mucoid, gummy, honey-like fluid. The secre- 
tion may be copious or scanty, according to the amount of cuta- 
neous disturbance. The patches are generally more or less tender 
or painful, and at times the seat of itching and burning. The 
course of the affection is generally chronic : it may continue in- 
definitely unless checked by treatment. Sometimes, however, the 
disease thus cures itself. In severe and protracted cases the hair- 
follicles are destroyed, and there results baldness. The causes 
which occasion this form of the disease rather than that usually 
encountered, namely, ordinary tinea tonsurans, are. not known. 
It is met with in the upper classes as well as among the poor, 
although more common among the latter. It is rare in Phila- 



TINEA SYCOSIS. 623 

delphia; less so, I believe, in New York. It is to be diagnosed 
from subcutaneous abscess, which it at times closely resembles. 
The treatment is that of tinea tonsurans, sulphurous acid proving 
especially useful in my hands. 

TINEA SYCOSIS. 

Syti., Sycosis Parasitica; Sycosis Parasitaria ; Sycosis Contagiosa ; Para- 
sitic Sycosis; Parasitic Mentagra ; Barber's Itch; Germ., Parasitare Bart- 
finrte ; Fr n Trichophytie Sycosique ; Sycosis Parasitaire. 

Tinea sycosis is a contagious, vegetable parasitic affec- 
tion, DUE TO THE TRICHOPHYTON, CONFINED TO THE HAIRY PORTION 
OF THE FACE AND NECK IN THE ADULT MALE, CHARACTERIZED BY 
DISEASE OF THE HAIR AND HAIR-FOLLICLE, INFLAMMATION OF THE 
SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE, AND THE FORMATION 
OF TUBERCLES AND PUSTULES. 

Symptoms. — The disease generally begins with one or more 
reddish, slightly scaly patches, the size of a small coin ; in fact, 
as tinea circinata. In the course of a few days the redness and 
desquamation become more marked, and swelling and induration 
are noticed. Soon the hairs also are noted to be affected ; they are 
dry, brittle, incline to break, and are perhaps already loose. The 
disease increases, until in a short time the skin becomes distinctly 
nodular and lumpy, with points of pustulation about the openings 
of the hair-follicles. Not "only the skin but also the deeper tissues 
are involved, giving rise to raised, thick, firm masses of induration. 
The surface is of a deep-reddish or purplish color ; has usually a 
passively congested appearance ; and is studded with variously 
sized discrete or confluent tubercles or pustules. 

The tubercular formations are characteristic of the disease. 
They vary as to shape and size, but are for the most part irregu- 
larly rounded and as large as split peas or half cherries. As a 
rule, they coalesce, producing large, uneven, lumpy patches, oc- 
cupying usually considerable surface.* In rare cases the lesion 
may be single, coin sized, sharply circumscribed, and prominently 
raised, as much as half an inch. The amount of suppuration 
varies, depending upon the irritation of the fungus and the grade 
of inflammation. In certain cases it is an early symptom, and 

* See my Atlas of Skin Diseases, Plate S. 



624 PARASITES. 

proceeds actively, pustules of all sizes forming about the follicles. 
At times these break down, and are succeeded by thick crusts 
similar to those of pustular eczema, which may be so abundant as 
completely to mask the true nature of the disease. Beneath them 
will usually be found an uneven, moist or excoriated, reddish sur- 
face, with yellowish points, discharging a glairy, glutinous material, 
and resembling in appearance the cut surface of a fig (whence the 
name sycosis). In other cases but slight pustulation takes place, 
the process being one rather of deep-seated tubercular induration 
throughout its course. 

The hairs are plainly diseased; they are dry and brittle, bent 
or broken off, either at their exit from the follicles or at a line or 
two above the level of the skin, and can be extracted without pain. 
Later, the hairs loosen spontaneously, through suppuration or dis- 
integration from excessive invasion of the fungus, and drop out, 
leaving the region partly or wholly devoid of hair. In other cases 
the hair-follicles and hairs are involved to a less extent, so that 
loose hairs are found only here and there; the disease being one 
midway between tinea circinata and tinea sycosis. The chin, the 
neck, and the submaxillary region arc the localities commonly at- 
tacked ; the upper portions of the cheeks and the upper lip are 
rarely invaded. The disease may occur on one side of the face 
only, or, as is usually the case, on both sides; not infrequently the 
whole of the region of the lower jaw is involved. The amount 
of itching, burning, and pain varies; at times these symptoms are 
slight, in other cases annoying or severe; they are, however, as a 
rule, disproportionate to the severity of the lesions and cutaneous 
disturbance, and are seldom so marked as in non-parasitic sycosis. 
The course of the disease is usually chronic. A few weeks gen- 
erally suffice for it to present its characteristic appearance, after 
which it may continue spreading or subside into an inactive state. 
When left to itself, it may last months or years. Unless thor- 
oughly treated, it tends to relapse. It may develop from a pre- 
vious tinea circinata of the non-hairy part of the face or of some 
other region of the body; or it may occur simultaneously with a 
tinea circinata of the general surface. 

Etiology. — The cause is found in the presence and growth of the 
trichophyton fungus, which invades the hair-follicle and hair. It 
is the same parasite as that of tinea tonsurans and tinea circinata. 



TINEA SYCOSIS. 625 

Its parasitic nature was pointed out by Gruby in 1842. It is emi- 
nently contagious, and is acquired in most cases at the hands of 
the barber. All individuals, however, are not equally susceptible 
to the influence of the parasite; out of a number who have been 
exposed to contagion, certain persons only will contract the dis- 
ease. Like the other vegetable growths, it seems to require some 
peculiar, unknown condition of the skin for its development. It 
is not a common disease. Its frequency varies greatly in different 
countries ; it seems to vary, moreover, in different sections of our 
own country. In Boston it is about as common as tinea tonsu- 
rans ; out of 5000 consecutive cases of skin disease met with in 
dispensary practice, White* reports 38 cases of tinea sycosis and 
42 cases of tinea tonsurans. Wiggles worth, f out of 1339 con- 
secutive cases of skin disease, reports 8 cases of tinea sycosis. In 
New York the disease is of decidedly less frequent occurrence ; 
BulkleyJ encountered but 2 cases among 1617 cases of cutaneous 
disease as met with in dispensary practice. In Philadelphia, in 
dispensary service, the proportion is even less ; out of 1267 con- 
secutive cases of skin disease observed at the Dispensary for Skin 
Diseases, no cases of tinea sycosis were recorded. The disease in 
this city, however, is by no means so rare as these figures would 
indicate, for my private practice not infrequently affords exam- 
ples. In Glasgow, Anderson § reports but 18 cases out of 10,000 
consecutive cases of skin disease in dispensary practice, and 6 
cases in 1000 cases of skin disease in private practice. In France 
tinea sycosis is without doubt much commoner than in any other 
country ; at the St. Louis Hospital, Paris, cases are of frequent 
occurrence. In Vienna, on the other hand, the disease is very 
seldom encountered. It occurs among all classes of men and at 
all periods of life, although more common between the ages of 
twenty and forty than later. It is met with in the weakly and in 
the robust, and does not appear to be in any way dependent upon, 
or influenced by, the state of the general health. 

Pathology. — The fungus finds its way into the hair-follicles, as 



* Bost. Med. and Surg. Jour., May 18, 1876. 

f Annual Keports of the Dispensary for Skin Diseases, Boston, 1873, 1874. 

X American Practitioner, May, 1875, and April and May, 1876. 

I Lancet, Nov. 11, 1871. 

40 



626 



PARASITES. 



in the case of tinea favosa, penetrates them deeply, and produces 
its mischief chiefly about the root and in the shaft of the hair. 
Both the follicle and the hair become invaded to such an extent 











I 



■- 






Fig. VIII.— Trichophyton, as found in Tinf.a Sycosis. (300 Diameters.) 
Short, stout hair of beard, with the root-sheath attached to root, showing free 
spores aud chains of spores. 

as to bring about inflammation, followed by more or less follicular 
suppuration and general infiltration of the tissues. The irritation 
caused by the parasite is great, occasioning inflammation of the 
subcutaneous connective tissue, and the well-known tubercular 
formations peculiar to the disease. They are firm, comparatively 
painless, and manifest but little disposition to undergo change, 



TINEA SYCOSIS. 627 

remaining so long as the fungus luxuriates, finally disappearing 
gradually without leaving scars. 

Under the microscope the affected hairs are seen to be swollen, 
at times twisted, and disintegrated about their roots. Their bulbs 
are often obliterated. About their exterior, especially around the 
root, and within their structure, the fungus is plainly discernible. 
It shows itself, as a rule, abundantly, and consists of both mycelium 
and spores, the spores predominating, as in the case of tinea ton- 
surans, although usually to a less extent. (For a description of 
the fungus, see Tinea Circinata and Tinea Tonsurans.) In hairs 
which have not been destroyed, mycelium may usually be found 
ramifying over the root, and in the root-sheath, which often comes 
away upon extraction attached to the root and bulb of the hair. 
In other cases the fungus is scanty, varying as to quantity in 
different hairs. 

Diagnosis. — Difficulty is occasionally experienced in distinguish- 
ing between tinea sycosis and sycosis non-parasitica. The points 
of difference, however, are usually so marked that error can 
scarcely occur. In tinea sycosis the skin and the subcutaneous 
connective tissue are extensively involved, as manifested by the 
induration and the formation of the characteristic tubercles. In 
sycosis non-parasitica the seat of the process is confined to the hair- 
follicles, the surrounding as well as the deeper tissues being im- 
plicated, as a rule, to a comparatively slight extent. The inflam- 
mation in sycosis non-parasitica is usually of an active type, and 
is followed generally by free suppuration ; in tinea sycosis it is 
less active, is deeper-seated, and is attended by less suppuration. 
The pain or itching in tinea sycosis is seldom severe, and usually 
less so than the appearance of the disease would indicate. In 
sycosis non-parasitica, in extensive cases, the pain and burning 
sensations are at times severe. The upper lip is rarely invaded 
in tinea sycosis; it is very frequently attacked in sycosis non- 
parasitica. The hairs in tinea sycosis are dull, dry, swollen, often 
twisted, and brittle ; in sycosis non-parasitica they are generally 
healthy in appearance. In tinea sycosis they are loose, and may 
be extracted without pain ; in sycosis non-parasitica they are often 
firmly seated in their follicles. In tinea sycosis the microscope 
reveals the parasite, the presence of which establishes the diagnosis 
conclusively. (See Tinea Circinata and Tinea Tonsurans.) 



628 PARASITES. 

Tinea sycosis bears also some. resemblance to pustular eczema 
of the face, but the history and course of the diseases are so dis- 
similar as scarcely to permit of their being confounded. Pustular 
eczema develops itself, as a rule, rapidly, and is accompanied with 
itching, burning, discharge, and crusting. The presence of the 
induration and tubercular formation, and the looseness of the 
hairs, will moreover serve to distinguish it from eczema. The 
disease at times resembles the vegetating syphiloderm as it attacks 
the face in the form of hypertrophic, superficially eroded, rasp- 
berry-like, moist or crusted papules. No ulceration, however, 
takes place in tinea sycosis. The microscopic examination of the 
hairs, moreover, together with the history, will clear away all 
doubt. Chronic, circumscribed tinea sycosis, where perhaps but 
one patch exists, might be mistaken for epithelial cancer; but 
with attention to the history, course, and clinical features of the 
disease, error is not likely to occur. It may also be confounded 
with indurated acne, from which, however, it may be known by 
its never appearing upon the non-hairy parts of the face, as the 
cheeks and forehead, the usual scats of acne. In doubtful cases, 
where, for example, acne shows itself about the neck, the hairs 
should be submitted to the microscope. 

Treatment. — Depilation and the use of parasiticides are both 
demanded. Where crusts exist, they should be loosened with 
inunctions of almond or olive oil, and removed by washings 
with soft soap and warm water, after which shaving is to be 
instituted. This is an important step in the treatment. The 
operation should be performed about every other day, allowing 
time for the hair to grow sufficiently to depilate. The process 
may be somewhat painful at first, but in a short time it may be 
readily accomplished. The operation is seldom so painful as 
one would suppose. One of the parasiticides should now be 
applied. On the following day thorough depilation is to be 
performed, in the manner described in connection with the treat- 
ment of tinea favosa. The condition of the hairs will be found 
to vary ; at times they are loose over the whole affected part, 
and may be extracted with ease, while in other cases they are 
so only here and there. Their state depends altogether upon 
the manner in which the parasite has attacked the skin and fol- 
licles, whether superficially or deeply. Shaving and depilation, 



TINEA VERSICOLOR. 629 

upon alternate days, should be perseveringly practised until the 
new hairs show themselves to be healthy. 

In the choice of a parasiticide one should be guided by the 
stage of the disease, its extent, and the general condition of the 
surface of the skin.- A weak or a strong preparation may be 
selected to suit the demands of the case ; for the first few days it 
is well not to employ too stimulating remedies. Corrosive subli- 
mate, two or three grains to the ounce of water or alcohol, consti- 
tutes an excellent lotion, suitable to any stage of the disease. 
The yellow sulphate of mercury, in the form of an ointment, 
thirty grains to the ounce, may often be used with the best of 
results. Of the milder remedies, hyposulphite of sodium, as an 
ointment, or as a lotion, a drachm to the ounce; and sulphurous 
acid, full strength or diluted, are the most valuable. In addition 
to these remedies, any of those recommended for the other vege- 
table parasitic diseases may be made use of. Whichever the 
remedy selected, it should be applied thoroughly twice or thrice 
daily in such a manner that it penetrates the hair-follicles. 

Prognosis. — The disease is sometimes rebellious; one or two 
months may be necessary to effect a cure. Relapses are liable to 
occur if the treatment be neglected or be discontinued too soon. 
Shaving should be persisted in for several months after all trace 
of the disease has disappeared. 

TINEA VERSICOLOR. 

Syn., Pityriasis Versicolor; Chloasma (Wilson); Mycosis Microsporia ; 
Germ., Kleienflechte ; 2<V., Pityriasis Versicolor. 

Tinea versicolor is a vegetable parasitic disease, due to 
the microsporon furfur, characterized by variously sized, 
irregularly-shaped, dry, slightly purfuraceous, yellowish, 
macular patches, occurring for the most part upon the trunk 
in adults. 

Symptoms. — The disease begins by the formation of pin-head 
and split-pea sized, yellowish spots, scattered usually here and 
there over the affected region. In the course of a few weeks or 
months they will have increased more or less in size, and will 
have undergone certain other changes, the disease now presenting 
the following more definite characters. As it is ordinarily en- 



630 PAEASITES. 

countered, the lesions vary considerably in size ; at times they are 
split-pea and finger-nail sized, in other cases much larger. They 
not infrequently unite and form patches which may occupy a large 
surface, as, for example, the greater part of the chest. In shape they 
are at first usually roundish; later, when they have coalesced, this 
form is usually lost, irregularly-shaped patches taking their place. 
The outline of the disease is generally sharply defined against the 
sound skin, more particularly around that portion which is spread- 
ing. Very rarely they may assume an annular form, as in the case 
reported by Unna.* The number of the lesions varies; there may be 
but two, three, or a half-dozen, or, on the other hand, as is usually 
the case, a great many. They are pale yellow, buff, tawny, or 
brownish yellow in color. In rare cases, in Oriental countries, they 
may even be black, as reported by Manson. At times they possess 
a reddish hue, due to hyperemia. In patients who are stout, and 
in those who perspire freely, a reddish tint is not infrequently noted, 
especially in summer. Occasionally, in sensitive skins, the lesions 
become the seat of considerable irritation and hyperaemia, in which 
case they may assume a variegated, whitish and pinkish, urticarial 
aspect, and may be slightly raised. In the usual form of the dis- 
ease, however, they are so slightly elevated above the level of the 
surrounding skin as to be scarcely perceptible. The patches are 
the seat of more or less furfuraceons desquamation, varying with 
the amount of bathing and perspiration, and the degree of scratch- 
ing to which they have been subjected. At times they have a 
smooth appearance and feel, but the scaling may always be detected 
by rubbing or scraping the surface. The scales are very fine, and 
are of a powdery or mealy character. The patches are made up 
entirely of these scales, which, although more or less adherent to 
the skin, may be readily scraped away with the finger-nail. If 
the surface be moist, they cohere, cake, and come away in masses 
or in rolls, as a soft, cheesy substance. 

The disease is peculiar in the regions upon which it shows itself. 
Its favorite seats are the chest, abdomen, groins, axillae, and arms ; 
it is also met with about the neck, on the back, and on the thighs. 
On the other hand, it is never encountered on the scalp, hands, or 
feet. Very rarely it is met with on the face. Practically con- 



* Viertelj. fur Derm. u. Syph., 1880, p. 167. 



TINEA VERSICOLOR. 631 

sidered, it is a disease of the trunk.* It shows no disposition to 
attack those regions which are exposed to the light and air. At 
times, in cases of long standing, the whole trunk, from the neck 
to the groin, the back as well as the chest, becomes affected, form- 
ing an almost continuous coating or sheet of disease. The lesions 
assume no tendency to symmetry ; they are, indeed, usually irreg- 
ularly distributed, and when extensive and in large patches give 
the skin a mapped appearance. Itching, varying, however, con- 
siderably in degree, is often present. Its severity depends upon 
the activity of the growth. In some cases it is marked. As a 
rule, it is more pronounced in fleshy than in spare individuals. 
On the other hand, cases are not rare in which there is no itching 
whatever. The course of the disease is variable; at times it 
spreads rapidly, in other cases very slowly. It is, as a rule, a 
persistent disease. Without treatment it may continue for an 
indefinite period ; examples are not uncommon where it has ex- 
isted for many years. Relapses are of frequent occurrence, even 
in those cases where the treatment has been most judiciously 
carried out. 

Etiology. — The cause of the disease is found in the presence upon 
the surface of the skin of a vegetable growth, called the micro- 
sporon furfur. It was discovered by Eichstedt, of Greifswald, 
in 1846.f The affection is contagious, although so only in a very 
low degree and only under favorable conditions. Cases are occa- 
sionally met with in which it has been communicated from hus- 
band to wife, and vice versa; also from sister to sister, and from 
brother to brother, particularly where they have occupied the same 
bed. Such instances, however, are exceptional. Its contagious 
properties are therefore feeble, differing in this respect from the 
other vegetable parasitic affections. It is usually met with upon 
persons between the ages of twenty and forty ; it seldom, if ever, 
occurs before puberty, and rarely after fifty ; I have never observed 
it in children. Both sexes are about equally affected. The health 
of those attacked varies. It is encountered in those enjoying the 
best of general health, also, and I think more frequently, in those 



* See Plate G- in my Atlas of Skin Diseases. 

f Froriep's ISTeue Notizen aus dem Gebiete der Natur- und Heilkunde, Bd. 
xxxix. p. 270. 



632 PARASITES. 

suffering from wasting diseases, particularly phthisis. It attacks 
the rich as well as the poor, and bathers as well as those who 
seldom bathe. 

It is a common affection, and is encountered in all parts of the 
world, although there is considerable variation in the frequency 
of its occurrence in different countries and places. Wilson.* in 
London, records 131 cases out of 10,000 cases of skin disease met 
with in private practice; Anderson,f in Glasgow, only 106 cases 
out of 10,000 cases of skin disease in dispensary practice. In our 
own country, White,J in Boston, reports 13 cases in 1000 cases of 
skin disease in private practice, and 14 cases out of 1000 cases 
among dispensary patients. Bulkley§ gives similar figures for 
New York, lie having encountered but 14 cases out of 1617 cases 
of skin disease in dispensary service. In Philadelphia, on the 
other hand, the disease is without doubt of more frequent occur- 
rence than in any of the above-named cities : at my Dispensary for 
Skin Diseases, 33 cases were recorded out of 1267 consecutive cases 
of skin disease, and at the clinic for diseases of the skin at the 
Hospital of the University of Pennsylvania, 21 cases were ob- 
served among 1205 consecutive cases of skin disease. According 
to the statistics of the American Dermatol ogical Association, 177 
cases were encountered among 16,863 cases of skin disease. In 
India and in Eastern countries generally the affection is exceed- 
ingly common. 

Pathology. — The microsporon furfur consists of mycelium and 
spores. The former is made up of slender, variously sized, for the 
most part short threads, which cro.-s one another in all direction-, 
forming an irregular, more or less intricate net-work. The threads 
vary considerably in their form ; they are straight or curved, stick- 
shaped, j tinted and angular, twisted or looped, fork-shaped, or 
crooked and wavy. They are simple and empty, or contain here 
and there spores and granules; the spores, often quite large, are 
particularly conspicuous about the joints. The ends of the threads 
are, moreover, often found tipped with single spores. The diam- 

* Journal of Cutaneous Medicine, vol. iii. Xo. 11. 
f Lancet, Nov. 11. 1871. 

X Third Annual Report of the State Board of Health of Massachusetts. 
Boston, 1872. 

$ American Practitioner, May, 1875, and April and May. 187 



TINEA VERSICOLOR. 



633 



eter of the mycelium varies from t^Vo'" (.0015 mm.) to -g^'" 
(.0038 mm.). The spores are small, variously sized and shaped 
(as in the case of the achorion Schonleinii), round, ovalish or 
irregularly rounded, highly refractive, grayish or pale-greenish 
bodies, with or without nuclei, having a marked tendency to 
aggregate and crowd together here and there in groups. This 




Tig. IX.— Microsporon Furfur. (500 Diameters.) 
Showing mycelium in various stages of development, groups of spores, and free spores. 



arrangement is peculiar, and does not occur in connection with 
any of the other vegetable parasites. Large numbers of spores, 
closely packed, are generally present in these masses. Free spores 
are also met with everywhere over the field. Their size varies 
considerably ; they measure from ywo'" (-0023 mm.) to yW 
(.0084 mm.). The growth is found in every stage of develop- 
ment from mycelium to spore, and with a sufficiently high power 
(five hundred diameters) presents even more varied forms than 
the achorion Schonleinii. (See Fig. IX.) The fungus is luxu- 
riant, and is always present in such abundance that no difficulty 
arises in discovering it. Its habitat is in the horny layer of the 
epidermis, which it permeates to such an extent as to take com- 



634 PARASITES. 

plete possession of it. It is the most superficially seated of all 
the vegetable parasites of the skin. It does not invade either the 
hair or the nail. It gives rise, as a rale, to no hyperaemic or in- 
flammatory symptoms. At times it grows with great vigor ; in 
other cases it seems barely able to sustain itself. As a rule, it is 
not tenacious of life, and may be destroyed without difficulty by 
any one of the numerous substances which exert a destructive 
influence upon vegetable organisms. 

Diagnosis. — Difficulty will rarely be experienced in recognizing 
the disease. At the same time, examples occasionally present 
themselves where, from some peculiarity in the shape, size, color- 
ation, or localization of the patches, the true nature of the affec- 
tion is not entertained. If the patch, however, be but suspected 
of being parasitic, there can remain no doubt as to its nature, for 
the microscope will show the presence of the fungus. The mode 
of making the examination is simple. A few of the scales are 
scraped from the surface with a blunt knife-blade or with the 
finger-nail, and placed upon a glass slide with a drop of liquor 
potassje, and covered with a thin glass cover. The specimen may 
be at once submitted to the microscope, a power of from two hun- 
dred and fifty to five hundred diameters being necessary to show 
the fungus to advantage. No difficulty will occur in finding the 
growth, for it i- always abundant. The seat of the affection, 
almost invariably upon the trunk, especially about the chest, 
more particularly the sides, and the abdomen, the yellowish or 
brownish color, and the furfuraceous desquamation of the patches, 
are also to be borne in mind. If a patch be rubbed or scratched 
with the finger-nail, the Bcales will fall in the form of a fine dust 
or powder; or, if the surface be moist from perspiration or other 
cause, the epidermis will cake and form into rolls. Beneath the 
scales the skin will appear pinkish or reddish, according to the 
amount of irritation. 

Care must be observed not to confound the disease with vitiligo, 
an affection of an entirely different nature, but one, nevertheless, 
which at times closely resembles tinea versicolor in some of its 
features. Vitiligo is an affection of the pigmentary system, whose 
seat is confined to the mucous layer of the epidermis ; in tinea 
versicolor the process, it will be remembered, is seated in the horny 
layer of the epidermis. If a patch of vitiligo be scratched with 



TINEA VEESICOLOK. 635 

the finger-nail, no scaling will take place. Chloasma is another 
disorder of the pigmentary system with which it may be con- 
founded. Here the process, as in vitiligo, consists in an increased 
pigment deposit, and is consequently seated in the mucous layer of 
the epidermis. Chloasma, moreover, as a rule, does not occupy 
the same regions as tinea versicolor; it is usually encountered 
about the face, a region very rarely attacked by the disease under 
consideration. The erythematous syphiloderm, in its latter stages, 
may also present a likeness to tinea versicolor ; but error in diag- 
nosis can scarcely occur if attention be paid to the characteristic 
features of either disease. It must be stated, however, that in 
practice the diseases are not infrequently confounded. In tinea 
versicolor the yellowish color, the variable size and shape, and the 
scaly surface of the patches, their course, and their seat, are all to 
be borne in mind. In syphilis the patches are usually indistinct 
in outline ; are seldom larger than a finger-nail ; present a more 
mottled appearance; are pigmented; are not surmounted with 
furfuraceous scales ; are not accompanied by itching ; and, finally, 
are apt to occur upon the face, limbs, hands, and feet, as well 
as upon the trunk. The diagnosis may always be definitely es- 
tablished by the microscope. The so-called pigmentary syphi- 
loderm is so peculiar, and, moreover, so rare, that it is not likely 
to be confounded with the disease under consideration. As a 
word of caution, it must not be forgotten that tinea versicolor is 
quite as liable to show itself upon a syphilitic as upon a non- 
syphilitic person ; the fact of an individual being syphilitic by no 
means precludes the possibility of contracting a vegetable parasitic 
disease. Finally, I may add that I have known cases where the 
patches of tinea versicolor have been regarded as the macular 
manifestation of leprosy ; so gross an error, however, it need 
scarcely be remarked, is not likely to occur with one at all familiar 
with the disease. 

Treatment. — The treatment is simple, and is followed by satis- 
factory results. A parasiticide of one kind or another, thoroughly 
applied, is all that will be found necessary for the complete re- 
moval of the disease. In the choice of a remedy, care should be 
exercised in selecting one of suitable strength, and at the same 
time one which may be conveniently applied by the patient. Strict 
attention to personal cleanliness should in all cases be enjoined. 



636 ' PARASITES. 

Frequent washings with sapo viriclis and water, and alkaline 
baths, consisting of two or three ounces each of carbonate of so- 
dium and potassium to thirty gallons of water, are useful; also 
baths of sulphide of potassium, two ounces to the bath. Sapo 
viridis may also be employed as follows. A piece of the soap the 
size of a walnut or larger, according to the amount of surface to 
be treated, is to be thoroughly rubbed into the affected skin every 
morning and evening for five or six days, one coating of soap 
being applied over the other. The patient during this period is 
not to be permitted to bathe. Four or five days are now allowed 
to elapse, when the first bath is ordered, after which the disease 
will be observed in many cases to have disappeared. If patches 
still remain, the same course may be repeated, or the frequent 
use of soft soap in connection with the plain bath relied upon to 
complete the cure. 

Good results are also obtained from the employment of oint- 
ments and lotions containing sulphite and hyposulphite of sodium. 
They maybe prepared in the strength of one drachm to the ounce 
of ointment or of water. Sulphurous acid, full strength or di- 
luted, is also a valuable remedy, applied as a lotion. Vleininckx's 
solution, diluted, one part to three or six, is also useful. Before 
using these preparations, the surface should be cleansed with water 
and soft soap. Corrosive sublimate will also be found serviceable 
in the form of a lotion, two or three grains to the ounce. Ander- 
son* gives the following formula, of which he speaks well: 

R Hydrargyri Chloridi Corrosivi, 9i ; 

S:i])unis Viridis, gii ; 
Alcoholis, 15 iv ; 
Olei Lavandulae, Qii. 
M. 

This is to be well rubbed into the affected parts night and morn- 
ing. Tincture of veratrum viride is also said to be efficacious. 
Boracic acid, in the form of a saturated solution, and diluted acetic 
acid are also useful. "Whatever remedy be employed, it is proper 
to continue treatment with it for several weeks after all symptoms 
have disappeared, to guard against relapses, which are liable to 

* Parasitic Affections of the Skin. Second edition, London, 18G8. 



SCABIES. 637 

occur if this precaution is not exercised. Should the patient 
manifest signs of general ill health and the disease prove intrac- 
table, in the form of repeated relapses, internal remedies, as may 
seem indicated, may be resorted to. 

Prognosis. — This is always favorable. For an ordinary case, a 
few weeks are usually sufficient to bring about a cure, although 
much will depend upon the manner in which the applications are 
made. Sometimes the disease is rebellious. The patient should 
be warned against the liability of a relapse. 

SCABIES. 

Syn., Itch; Ger?n., Kratze ; Fr., Gale. 

Scabies is a contagious, animal parasitic disease, due to 
the sarcoptes scabiei, characterized by the formation op 
cuniculi, papules, vesicles and pustules, followed by exoo 
riations, crusts, and general cutaneous inflammation, accom- 
panied with itching. 

Symptoms. — Inasmuch as the disease presents a- very different 
appearance as it is seen in its early or its later stages, it will be 
necessary to describe its course from the date of contagion. The 
itch mite no sooner finds itself upon the skin than it begins its 
work of burrowing ; and here it may be mentioned that it is the 
female only which penetrates the epidermis. Once within the 
skin, a burrow, or cuiriculus, is soon formed, in which numerous 
eggs are deposited, and which, moreover, serves as a habitat for 
the female during her life. The male is said never to enter the 
skin, but to live upon the surface. According as the mite pene- 
trates superficially or deeply, and according to the susceptibility of 
the skin, will one or another lesion be produced. After a certain 
time from the date of contagion a variable number of mites will 
have been hatched forth, all of which at once begin to care for 
themselves and to burrow. Thus the early symptoms of the dis- 
ease are manifested by the presence of a source of irritation at 
various points, characterized by the formation of minute more or 
less inflammatory puncta, papules, and vesicles. If the parts be 
now carefully examined here and. there, the beginning of a cu- 
niculus may usually be seen ; although at this stage of the disease 
these will not have been formed to any extent. The lesions may 



638 PARASITES. 

be either confined to a small area or be general ; they may exist 
upon the hands alone, the parts usually first invaded, or they may 
be distributed over various regions. They increase rapidly, and 
in the course of a fortnight or three weeks the disease generally 
appears fully developed. The symptoms now consist of distinct 
cuniculi, numerous small papules, distended vesicles, and pustules, 
varying in size, excoriations, scratch marks, fissures, torn vesicles, 
and pustules with crusts and blood crusts, all seated upon a more 
or less acutely inflamed skin.* Not one or two but a number of 
lesions, it will be seen, go to make up the picture of scabies as 
it exists when fully developed. It is, indeed, by this multiform 
character of the lesions that the affection is best known. The 
disease spreads day by day, until finally, in the course of a month 
or six weeks, the whole cutaneous surface is involved, certain re- 
gions of the body always suffering more markedly than others, 
showing at times an extensive inflammation of the tissues. The 
older the scabies the greater will be the cutaneous disturbance, 
although by no means the more distinct the characteristic Lesions, 
for these after a time become almost unrecognizable amid the 
crusts and excoriations. 

Having thus described the general course of the disease, it i- in 
place to refer to the individual lesions. The burrow, or cuniculus, 
as it is termed, is formed by the mite entering the skin and making 
its way beneath the horny layer of the epidermis, which is raised 
very much as a mole undermines the ground. It is to be seen as 
a slight linear elevation of the epidermis, varying from half a line 
to four or five lines in length, one or two lines representing the 
average length, having usually an irregular or tortuous course. 
In color it is whitish or yellowish, with a dotted, speckled look-, 
or blackish, varying with the occupation of the patient and the 
amount of extraneous matter which has collected upon the sur- 
face. At either end it terminates abruptly, exhibiting usually 
darkish points; the more prominent and usually lighter of these 
represents the mite, which lies embedded in the mucous layer of 
the epidermis. Burrows, such as described, are commonly seen 
only about the fingers, for upon other parts of the body they be- 
come scratched before they have had time to arrive at any size. 

* See my Atlas of Skin Diseases, Plate Q. 



SCABIES. 639 

The papules, vesicles and pustules are peculiar, and differ in 
their appearance and course from those observed in other diseases. 
All of these lesions may usually be seen at the same time, in vari- 
ous stages of development. The papules are usually numerous, 
always small, and are generally the first lesions to make their ap- 
pearance. Often the disease does not get beyond the papular stage. 
The vesicles may be either minute or large ; ordinarily they are 
of various sizes and shapes ; have an inflamed base ; and stand 
forth prominently. Upon their summits cuniculi are sometimes 
seen. The vesicles may remain, or they may pass into pustules, 
which, if not disturbed, may increase to the size of split peas and 
larger. When large, they are apt to be more or less irregular in 
outline. They show no regularity of distribution. 

The scratching of the patient produces secondary lesions, which 
play an important part in the disease. These scratch marks con- 
sist of excoriations of various kinds ; torn papules, vesicles and 
pustules, lacerations of the epidermis and corium, and wounded 
follicles, being among the most conspicuous. Crusts, composed of 
blood, serum and pus, of all forms and sizes, follow these lesions, 
and are usually present in abundance, the amount depending upon 
the length of time the disease has existed, as well as upon the 
natural susceptibility of the skin and the degree of scratching 
indulged in. Lastly, the general cutaneous inflammation, or der- 
matitis, accompanied by infiltration, thickening, and pigmentation, 
is to be taken into consideration. As a rule, all of the symptoms 
referred to are present at the same time, and it will be seen that 
considerable tissue disturbance must necessarily be present. As 
remarked, however, this varies, according to the natural sensi- 
bility of the skin, the general nutrition and health of the individ- 
ual, mechanical irritation, in the form of injudicious treatment, 
scratching, and other circumstances. 

The regions of the body attacked are characteristic. The affec- 
tion usually begins about the hands, and especially the fingers. 
The wrists, penis, and mammse are generally next invaded, fol- 
lowed by more or less eruption about all of the softer tissues of 
the trunk. The sides of the fingers and the folds where they 
join the hands are the particular localities attacked. In the male, 
the penis, owing to contact with the hands for the purpose of 
urinating, is almost invariably affected. In the female, the 



640 PARASITES. 

mamma, notably around and upon the nipples, usually show 
signs of the disease. The umbilicus, axillre, and buttocks in 
both sexes are commonly invaded. The lower limbs are seldom 
involved to any great degree, except in cases of long duration : 
the toes, however, particularly in children, are often the seat of 
the affection. Itching, which is always present in a greater or less 
degree, is also a prominent symptom. It begins as soon as con- 
tagion has taken place, gradually increasing in intensity until it 
becomes severe. It varies greatly, however, with the suscepti- 
bility of the skin, as well as with the temperament of the in- 
dividual. It is usually much worse at night. 

In those predisposed to eczema, this disease, in addition to the 
simple dermatitis, is provoked by the itch mite in the same manner 
as by any other penetrating irritant. Hence, in countries where 
scabies is common, examples of the disease combined with eczema 
are by no means rare. On the other hand, where the patient pos- 
sesses no disposition to the development of eczema, J hold that the 
disease produced by the mite is a simple dermatitis, characterized 
by the lesions already specified, which invariably terminates in 
more or less rapid recovery so soon as the cause has been removed. 
Sometimes scabies continues for months or years before it is 
detected or cured, in which ease the symptoms are all greatly 
exaggerated.* 

Etiology. — There is one cause only of the disease, namely, the 
presence of the sarcoptes scabiei. None are exempt from its 
ravages. It attack- all indiscriminately wherever the opportunity 
of burrowing itself into the tissues is offered. It arises from con- 
tagion, and only from contagion. This may be direct or indirect: 
the former when the mite is transferred directly from one person 
to another, as by a shake of the hand; the latter when it occurs 
through the medium of something which for the time hold- the 
mite, as, for example, the bedding or the clothes. Secondarily, 
much of the disease which exists is caused by the scratching of 
the patient. 



* The so-called " Norwegian Scabies" may be cited as an example of chronic 
scabies. Here the disease has often lasted a lifetime, the whole integument 
being in a chronically inflamed state and covered with pustules and extensive 
crusts. 



SCABIES. 641 

Scabies occurs in persons of all ages, from infancy to old age, 
as well as in those in every walk of life ; although, on account of 
inattention to cleanliness, the wearing of the same underclothes 
for a long time, and the more frequent sources of contagion to 
which the poor are subjected, it is of more frequent occurrence 
among this class. It is somewhat commoner in men than in 
women, from the fact that men are more apt to sleep together 
than women. It exists much more extensively in some commu- 
nities than in others. It is the commonest of all cutaneous dis- 
eases in the various countries of Europe. In Glasgow, according 
to the statistics of Anderson,* it is of unusually frequent occur- 
rence, 2527 cases having been encountered among 10,000 consec- 
utive dispensary cases of skin disease, and 44 cases out of 1000 
cases in private practice. In London, Mr. Wilson f reports 308 
examples among 10,000 cases of cutaneous disease, as observed in 
private practice. In both Paris and Vienna scabies is exceedingly 
common, more so in the first-named city. 

In the United States, at the present time, it is rare, varying 
considerably, however, in the frequency of its occurrence in the 
different large cities. The statistics of the American Derniatologi- 
cal Association give 148 cases among 16,863 cases of skin disease. 
It is more prevalent in seaport than in inland towns. White,! 
of Boston, reports 139 cases among 5000 consecutive cases of skin 
disease as met with at the out-door department of the Massachu- 
setts General Hospital. In New York the disease is encountered 
more frequently; Bulkley§ gives 62 cases in 1617 cases of skin 
disease as observed in dispensary practice. In Philadelphia, at 
my Dispensary for Skin Diseases, there were but 9 cases out of 
1267 consecutive cases of skin disease; while at the clinic for cu- 
taneous diseases at the Hospital of the University of Pennsylvania, 
only 3 cases were encountered among 1205 consecutive cases of 
skin disease. During the period of the late civil war the disease 
was much more prevalent throughout the country. The so-called 
"army-itch" possesses no peculiarities, and is to be regarded as 
ordinary scabies. 

* Lancet, Nov. 11, 1871. 

f Journal of Cutaneous Medicine, vol. iii. No. 11. 
% Bost. M<»d. and Surg. Jour., Jan. 27, 1876. 
I Anier. Pract., May, 1875, and April and May, 1876. 
41 



642 



PARASITES. 



Pathology.— Under this head may be described the anatomy 
of the mite, its habits of life, its habitat, and the lesions to which 
it gives rise. The sarcoptes scabiei (termed formerly sarcoptes 
hominis, by Raspail, and acarns scabiei, by De Geer) is a minute 
creature, barely visible to the naked eye as a yellowish-white, 
rounded body. It belongs to the class Arachnoidea, order Acarina, 
and family Aearidse. The female is usually met with, the male 
probably taking no part in causing the cutaneous lesions, and 




Fio. X.— Sarcoptes Scabiei. (125 Diameters.) 
Female. Ventral surface. 



Fig. XI.— Sarcoptes Scabiei. (126 Diameters.) 
Male. Ventral surface. (After Lanquetin.*) 



for this reason being very rarely encountered. The adult female 
has an ovoid body, convex on the back and flat on the holly, 
marked with two slight indentations on either side, and numerous 
transverse, undulating lines running over its ventral surface. (See 
Fig. X.) On the back are rows of conical, tooth-like prominences, 
or spines, with on either side of the posterior part of the body a 
series of larger, spike-shaped processes. The head is small, of a 
rounded oval shape, and is closely set in the body ; it is a complex 
structure, made up of palpi and mandibles, and is provided with 
six small hairs. Eves do not exist. The legs are conspicuous and 



* Notice sur la Gale et sur 1' Animalcule qui la produit. Avec planches 
gravees. Seconde edition, Paris 1859. 



SCABIES. 643 

are eight in number, four being situated close to the head, and 
four posteriorly. The four front legs are short, stout, conical or 
teat-shaped, jointed bodies, and are provided with stalked, cup- 
shaped suckers, and hairs. The hinder legs come off from the 
posterior half of the middle of the body, are less bulky than the 
front legs, and are each armed at their extremities with a long, 
curved bristle. In addition to the legs there are bristles which 
come off from the body, two on either side and four posteriorly. 
The female is much larger than the male (almost twice the size), 
and varies from \'" (.3022 mm.) to \'" (.4232 mm.) in length, and 
from \>" (.2645 mm.) to \'" (.3526 mm.) in breadth. The male 
in general structure differs but little from the female ; the last pair 
of posterior legs, however, are provided with stalked suckers in 
the place of bristles as in the female ; the organs of generation, 
moreover, are conspicuous. The young, or larva?, of either sex, 
may be recognized by their possessing but two hind legs.* 

The female finds her way by boring through the horny layer 
into the mucous layer of the epidermis, and, being impregnated, 
begins at once laying her eggs and at the same time making her 
burrow. A variable number of eggs are deposited, usually about 
a dozen, after which she perishes in the skin. They are oval, and 
average about ^'" (.1763 mm.) in length. If a cuniculus be 
excised with a knife or scissors, and placed beneath a microscope, 
it will be found to contain the mite, with usually from ten to 
fifteen eggs arranged in a row, egg-shells, more or less broken, 
and small, roundish, dark-colored specks, — the excrement. The 
ova hatch out in eight or ten days. The female may be captured 
by puncturing the blind end of one of the longer burrows (at 
which end the mite will always be found, appearing as a whitish 
or dark point) with a pin. With a little practice, no difficulty 
will be experienced in securing the prize. Before the operation is 
attempted, however, care should be observed in ascertaining the 
exact seat of the mite. 

Scabies must be viewed as an artificial inflammation of the skin. 
It is brought about by the peculiar ravages of the insect, together 

* For a complete treatise on the anatomy of the sarcoptes scabiei, see the 
superb monograph of M. H. F. Fiirstenberg, entitled " Die Kratzmilben der 
Menschen und Thiere, mit 15 lithographirten Taflen, 10 Umrissfiguren und 
3 Holzschnitten." Leipzig, 1861. 



644 PARASITES. 

with the scratching on the part of the patient. The lesions pro- 
duced, both primary and secondary, with the exception of the bur- 
rows, are very similar, from an anatomical point of view, to those 
encountered in certain of the varieties of eczema. The amount of 
cutaneous disturbance varies considerably ; as a rule, it is marked, 
the degree of inflammation depending upon the duration of the 
disease, and, more particularly, upon the sensibility of the skin. 
With this latter point will rest not only the grade of inflammation, 
but also the amount of scratching. According as the skin is or is 
not sensitive Will the disease prove comparatively light or severe 
in type. In cases where there is a predisposition to eczema, this 
disease will undoubtedly be called forth, complicating the original 
affection; such instances are sufficiently common in countries where 
scabies is of frequent occurrence.* 

Diagnosis. — Bearing in mind the various points which denote the 
presence of the disease, the diagnosis, as a rule, is easy. At the 
same time it must not be forgotten that the affection is liable to be 
encountered in all stages, from the day of contagion to the period 
of its highest development, and that the symptoms vary greatly 
according to its age, the influences to which it ha- ben exposed, 
and other circumstances. The presence of the burrow suffices for 
the diagnosis, and should be looked for as soon as the disease is 
suspected ; but it is by no mean- always to be found. In the fust 
Btage typical burrows do not exist, for a certain length of time is 
required for the mite to produce them; after the disease ha- con- 
tinued for some time they become, on the other hand, in a great 
measure obliterated by the scratching of the patient. 'Jims their 
demonstration often proves a matter of difficulty. Their remains, 
however, in old cases, may generally be noticed. The mile itself 
may usually be extracted with a pin from a recenf vesicle or bur- 
row ; but failure in this direction should by no means cany weight 
in the diagnosis, for it requires sharp eyes and a certain amount of 
dexterity to capture the intruder, even when in full sight. The 
supposed burrows, moreover, may upon closer inspection prove to 
be but lines of abraded epidermis, more or less filled with extra- 



* In this country it is rare to see true eczema caused by scabies. The affec- 
tion, as a rule, disappears rapidly upon the employment of a suitable para- 
siticide. 



SCABIES. 645 

neons matter. They are not always to be plainly seen. They 
are most numerous and marked where the skin is thin and pro- 
tected from external influences. In the majority of cases they are 
to be detected only upon the sides of the fingers. 

The region of the body affected must always point strongly to 
scabies. The hands, wrists, forearms, penis, the mammae and 
nipples in the female, the buttocks in both sexes, particularly in 
children, and the trunk, are all more or less involved. The face 
and scalp remain free, except in the case of infants. The mul- 
tiformity of the eruption, moreover, where the disease is well 
developed, consisting of a generally inflamed surface, papules, 
vesicles, pustules, scratch marks, excoriations, crusts of blood and 
pus, should in itself lead to a suspicion of the disease, especially 
if it occur upon the parts specified. It may, indeed, usually be 
recognized by the general picture. A history of contagion, also, 
will often be furnished. 

There are, nevertheless, several diseases with which it may be 
confounded. It is most liable to be mistaken for vesicular and 
pustular eczema. As has been already stated, the two diseases 
may exist together as a complication ; but such an occurrence is 
rare. The presence of the mite, the burrows, the more or less 
discrete vesicles and pustules, with irregular dots or dotted lines 
in their roofs, the regions affected, the gradual accession in the 
severity of all the symptoms, the steady increase day by day of 
itching and consequent scratching, and, lastly, the proof of con- 
tagion, all speak strongly in favor of scabies and directly against 
eczema. The affection may be distinguished from pediculosis by 
the character of the anatomical lesions, as well as by the regions 
involved. Finally, it is to be remembered that scabies may exist 
intercurrently in connection with various skin diseases. 

Treatment. — Once recognized, the disease is in most cases 
speedily cured. External means alone are required. Before 
prescribing, there are several points which should be taken into 
consideration. The age of the patient, whether an infant, child, 
or adult, is a matter of some importance in deciding upon the 
remedy to be used. The natural sensitiveness of the skin, whether 
delicate and fine or coarse and harsh, should also be determined. 
A knowledge of the duration of the affection, as well as of 
the amount of secondary disturbance in the form of excoriations, 



646 PARASITES. 

crusts, and infiltration which may exist, is likewise important. 
The objects to be gained in the treatment are twofold, namely, 
the destruction of the parasite and at the same time relief to the 
inflamed skin. Ordinarily, the artificially disturbed tissues re- 
cuperate rapidly after the destruction of the mite, so that no 
special remedies are demanded for this condition. If eczema, 
however, exist in connection with the scabies, or if the case be 
a severe one of long duration, it may be weeks before complete 
recovery takes place. 

Sulphur, in one form or another, is the remedy which may be 
relied upon. It is best employed as an ointment. The strength 
should vary with the case at hand, for if used too strong where 
there is a high degree of inflammation it acts also as an irritant 
to the skin. A drachm and a half or two drachms to the ounce 
will be found suitable for the majority of cases. Before applying 
the ointment, the patient should receive a thorough washing with 
soft soap and water, to be followed, if possible, by a warm bath. 
After this it should be firmly and slowly rubbed into every portion 
of the body (except the head in the case of an adult), special 
attention being devoted to the hands, fingers, and other parts 
usually the seat of the disease. About an ounce should be con- 
sumed for each application. The rubbings are to be repented 
twice daily for three days, at the expiration of which time a bath 
with soap may be taken. The itching will usually abate consid- 
erably after the first day, although it will not cease entirely until 
some days have elapsed after the destruction of the parasites, owing 
to the general cutaneous inflammation and irritation which exist 
The applications, therefore, are not to be persisted with because 
the itching continues, but should be Stopped after the third day, 
at least until it can be ascertained whether or not the mites have 
been destroyed. Vleminckx's solution may also be referred to 
as a useful remedy. 

Balsam of Peru, in itself a parasiticide, may be advantageously 
combined with sulphur, constituting an excellent preparation for 
children, as in the following formula : 

R Sulphuris Sublimati, 51 ; 

Balsami Peruvian!. 3-- ; 

Adipis, ^i. 
M. Ft. UDgt. 



SCABIES. 647 

Styrax, also a balsam, is likewise valuable. It is well spoken of 
by Anderson,* and is by him even preferred to sulphur, employed 
according to the appended prescription : 

R Styracis Liquidi, gi ; 

Adipis, ^ii. 
Liquefac et cola. 

It possesses the advantages of having a pleasant odor, of being 
clean, and, moreover, unirritating to the skin. Tar, oil of cade, 
sapo viridis, carbonate of potassium, lime, petroleum, the essen- 
tial oils, and staphisagria, may all be employed, with or without 
sulphur, in various combinations. They constitute the principal 
ingredients of numerous well-known prescriptions, some of which 
have had considerable repute in the treatment of this disease. A 
few of these only need be referred to : 



R Potassii Carbonatis, gi ; 

Sulphuris Sublimati, jjii : 

Adipis, ^iss. 
M. Ft. ungt. 



This is Hardy's modification of Helmerich's ointment, and is the 
preparation used at the St. Louis Hospital, Paris. The patient is 
well rubbed with sapo viridis for half an hour, when he is placed 
in a warm bath and permitted to remain there another half-hour, 
after which the above ointment is thoroughly rubbed into the skin, 
and the cure thus completed. This course of treatment, though 
rapid and, as a rule, effectual, is at the same time somewhat irri- 
tating to the skin ; it was first instituted by Hardy, and for a 
large hospital service fulfils its purpose.f 

"Wilkinson's ointment, as modified by Hebra, is a preparation 
much in vogue in the Vienna General Hospital ; the following 
is the formula : 



* Treatment of Diseases of the Skin. London, 187?. 

f At the St. Louis Hospital, Paris, the number of scabies patients is very 
large : not infrequently as many as fifty cases per day apply for treatment. 
They are not admitted into the hospital, but receive the cure described in a 
department devoted to this purpose. 



648 PARASITES. 

R Sulphuris Sublimati, 

Olei Cadini, aa [jii; 

Creta? Proeparatre, ^iiss ; 

Saponis Viridis, 

Adipis, aa §i. 
M. Ft. ungt. 

Patients are rubbed morning and evening for two days, after 
which nothing is done for a week, when, for the first time, a warm 
bath is ordered, and the treatment concluded. The preparation, 
though efficacious, is by no means elegant, and is more suitable for 
hospital than for private practice. 

The patient should always be cautioned concerning the conta- 
gious nature of the disease. It is advisable to wear the same 
underclothes during the treatment, and afterwards to have them 
boiled. 

Prognosis. — This is always favorable, a week usually sufficing 
for the cure, where the disease is not of long standing. If marked 
secondary lesions exist, longer time may be necessary to restore the 
skin to health. Relapses occur only in cases where the treatment 
has been but imperfectly carried out, or where the individual has 
re-contracted the disease. 

Leptus. — Two species of leptus which are known to attack 
man are described by Prof. Riley* as occurring in the United 
States, both of which arc sufficiently common in our Southwestern 

States. 

Leptus Americanus, or American Harvest Mite. — This is a 
minute, active, brick-red colored, elongate pyriform creature with 
six long legs, barely visible to the naked eye. It is found upon 
the scalp, in the axillae, and on other parts of the body, and more 
frequently upon children than upon adults. It docs not completely 
bury itself in the flesh, but insinuates the anterior portion of the 
body only beneath the skin, causing a small inflammatory papule. 

Leptus Irritans, or Irritating Harvest Mite.f — This is the better 
known of the two, and differs from the preceding merely in having 

* American Naturalist, vol. vii. p. 16. 

j This is very closely allied to the species met with in various parts of 
Europe and known as leptus (or "acarus") autumnalia. It is also termed 
"harvest-bug" and " mower's mite.' : In France it is known as "roug 



FILARIA MEDINENSIS. 649 

a roundish oval form. It gives rise to considerable annoyance, 
burying itself in the skin and causing irritation and inflamma- 
tion characterized by papules, vesicles, and pustules. It attacks 
especially the ankles and legs. It is met with in the summer 
and autumn in corn-fields, upon low bushes, in the grass and weeds 
along the banks of rivers, and in swampy places. It is said to be 
very common along the Mississippi River. The little red mite 
encountered in the swamps and on the low ground of Penn- 
sylvania, New Jersey, and Delaware, especially about blackberry 
bushes, is in all probability the same species. The disease is best 
treated with mild parasiticides, as, for example, a weak sulphur 
ointment, after the manner of scabies. 

Pulex Penetrans, Rhinochopeion Penetrans, or Sand 
Flea. — The sand flea (called also "chigoe," "chigger," and "jig- 
ger") is a small, almost microscopic creature, similar in its general 
anatomy to the common flea. It possesses, however, a proboscis 
which is as long as its body. It perforates and burrows into the 
skin, and in the course of a few days produces a painful inflam- 
mation accompanied with swelling, large vesicles or pustules, and, 
at times, extensive ulceration. The impregnated female alone 
enters the skin and causes the mischief. It attacks the feet, and 
more particularly the toes, beneath and alongside of the nail, where 
the ova are deposited. It is met with in tropical countries, being 
common in the West Indies, and in Central and South America. 
It is also met with in our Southern States. The treatment con- 
sists in extracting the intruder, which comes away in the form 
of a sac or bag as large as a small pea, being in the abdomen 
enormously distended with ova. The various essential oils are 
'used about the feet as a preventive against the attacks of the 
parasite. 

Filaria Medinensis. — This parasite (known also as the 
"Guinea-worm" and " dracunculus") is found only in tropical 
countries, and more particularly along the west coast of Africa, 
in Senegal and Guinea, and in Egypt, Persia, and India. In the 
central provinces of India, Dutt* reports the disease very common, 

* Brit. Med. Jour., 1880; also New York Med. Kec, vol. ii., 1880. 



650 PARASITES. 

one hundred and seventy-eight cases having been under his care 
from one village. It attacks the skin, giving rise to marked inflam- 
mation, which manifests itself in the form of a species of boil or 
painful tumor. The full-grown worm is about one-half or three- 
quarters of a line in thickness, and varies from several inches to 
three feet in length according to its age. It has a roundish flat- 
tened form, tapers at each end, and is of a milk-white color. The 
young worm, when of microscopic size, finds its way by boring 
into the skin and deeper tissues, and there takes up its habitat. 
It remains in the integument in, as it were, a latent state for a long 
period, usually months, during which time it grows to the size 
above indicated. Sooner or later local inflammation is set up in 
the form of a pointed tumor, accompanied by more or less swelling 
and pain, which breaks, showing the presence of the worm. One 
worm only is present in each tumor, although a number of them 
may infest different regions of the body at the same time. The 
lower extremities, especially the feet, are the parts generally at- 
tacked. The disease is usually contracted in swampy places and 
on low grounds. The treatment consists in extracting the worm 
inch by inch, from day to day, as soon as it makes its appearance 
at the surface of the skin, care being taken not to break the crea- 
ture in the operation. In a case treated by Tilbury Fox with the 
internal administration of assafcetida in liberal doses, as proposed 
by llorton, the tumor being poulticed, in five days the worm had 
extruded itself to the extent of an inch and a half, and the follow- 
ing day was found lying in the poultice. It measured twenty-three 
and a half inches.* 

Cysticercus Cellulosje.— Cases of cysticerei in the skin 
and subcutaneous tissues have been reported by Lewin,f Gutt- 
mann,| and Schiff.§ The disease is characterized by more or 
less numerous tumors varying in size from a pea to a hazel- 
nut, situated under rather than in the skin. They are rounded 
or ovalish, smooth, elastic, firm or even hard, and movable. New 

* Lancet, March 8, 1879. 

f Charite Annalen, 1877, p. 609. See also Viertelj. fur Derm. u. Syph., 
Jahrg. IV., Heft 4. 

X Berlin. Klin. Wochenschr., Xo. 26, 1877. 

I Viertelj. fur Derm. u. Syph., Jahrg. VI., p. 275, 1879. 



DEMODEX FOLLICULORUM. 651 

tumors usually show themselves from time to time. They are 
not painful on pressure, but they may be somewhat so sponta- 
neously. Having attained a certain size, they may remain un- 
changed for years. They may be mistaken for lipoma, carcinoma, 
or sarcoma ; also for epithelial molluscum, sebaceous cyst, and 
especially syphilitic tumors. Microscopic examination reveals the 
presence of cysticerci. 

CEsteus, Breeze, Gad, or Bot-Fly. — This parasite not in- 
frequently attacks man in Central and South America, and is also 
met with elsewhere. The ova are deposited by the fly in the 
skin, and there form inflammatory, boil-like tumors or swellings, 
with a central point or aperture which discharges a sanious fluid. 
The disease may also take on a linear, tortuous, or serpiginous 
form. In the course of time the presence of the worm, grub, or 
bot is discovered, which may be squeezed out or extracted. The 
various exposed portions of the surface are liable to be attacked, 
particularly the neck, back, and extremities. Walker* describes 
a case, occurring in Shetland, in which the lower part of the back 
of a woman was the seat of the disease, which was character- 
ized by a reddish, purplish, tortuous line, resembling an inflamed 
lymphatic vessel, from the inflamed end of which the grub, or so- 
called " warble," escaped through suppuration. According to 
Walker, the disease is not uncommon in Shetland, and is encoun- 
tered invariably in women. McCalmanf and W. G. Smith J also 
report similar cases in which dipterous larvae were extracted. My 
own experience furnishes a like case to that of McCalman. The. 
fly often deposits the ova unknown to the individual. There are 
several species of CEstrus which infest the human skin, of which 
CE. bovis is the most common. There is probably no species CE. 
hominis. 

Demodex Folliculorum. — This minute creature (also desig- 
nated steatozoon, entozoon, acarus, and Simonea, folliculorum) 
inhabits the sebaceous follicles of healthy, normal skin, and con- 



* Brit. Med. Jour., Feb. 12, 1870. 
flbid., July 19, 1879. 
% Ibid, Oct. 1, 1881. 



652 



PARASITES. 



sequently gives rise to no symptoms whatsoever of disease. 
According to Megnin,* it forms the only genus of a family 
of demodicides. A single species only occurs upon man, those 
found upon the dog, cat, sheep, and other animals being distinct, 
and not transferable to the skin of man. It is microscopic, vary- 
ing in length from fa'" (.1763 mm.) to \'" (.3526 mm.), and 



:>.-/i 






FlO. XII.— DeKODZX FOLLICOXOBC*. (300 Diameters.) 
Ventral surface. (After Simon.) 

has an elongated, rounded, worm-like form, made up of a head, 
a thorax, and a long abdomen. Other, shorter form> are also 
found. From the thorax come off eight, short, stout, conical 
legs, all of the same size. The larva has only six legs. The 
abdomen is usually from two to three times the length of the 
thorax, and tapers off to a rounded point. (See Fig. XII.) 

The parasite exists in the sebaceous glands of the skin, in both 
sexes, especially about the face, nose, ears, back, and chest, and 
lives on sebaceous matter. It is said not to occur in infants. It 
is entirely inoffensive, and is met with in healthy skin quite as 



* Jour. d'Anat., March, 1877. 



PEDICULOSIS. 653 

often as in those cases where the sebaceous glandular system is 
markedly disturbed, as, for example, in acne or in comedo. All 
persons, however, do not seem to possess the creatures ; they are 
more apt to be present in thick, greasy skins than in thin, dry 
skins. They occur as often, at least, as two or three times in ten 
persons. Two, three, or more of them often exist in one follicle. 
They are found embedded in the sebaceous matter, lying length- 
wise with the follicle, with the head directed inwards. No diffi- 
culty is experienced in obtaining them from a likely subject. A 
prominent or patulous follicle or a comedo upon the nose or 
forehead may be squeezed out, and the contents placed on a glass 
slide with a drop of olive oil and covered with a thin glass, 
when, with a power of from one to three hundred diameters, one 
or more of them will be usually found. The parasite was dis- 
covered by Henle, in 1841, and also, at about the same time, by 
Gustav Simon, of Berlin. 

PEDICULOSIS. 

Syn., Phtheiriasis ; Phthiriasis ; Morbus Pedicularis ; Pedicularia ; Malis 
Pediculi ; Lousiness; Germ., Lausesucht ; Fr., Phthiriase ; Maladie Pedi- 
culaire. 

Pediculosis is a contagious, animal parasitic affection, 
characterized by the presence of pediculi, and the lesions 
which they produce, together with scratch marks and exco- 
riations. 

Symptoms. — Three varieties of the disease are encountered, 
which are designated according to the names of the species of 
pediculi, or lice. The parasites (belonging to the class Insecta, 
order Hemiptera, and family Pediculidae) are named pediculus 
capitis, pediculus corporis, and pediculus pubis, frequenting, re- 
spectively, the head, body, and pubes. Their ravages are often 
extensive. They always occasion more or less discomfort, and at 
times great distress. The symptoms to which they give rise are 
somewhat different, and hence call for separate consideration. 

Pediculosis Capitis. — This is due to the presence of the pe- 
diculus capitis, or head louse. (See Fig. XIII.) It is found upon 
the scalp, and, as a rule, only upon this region of the body; occa- 
sionally, however, in elderly, bedridden subjects, it is met with on 



654 



PARASITES. 



the general surface. It has an elongate ovalish shape, consisting 
of head, thorax, and abdomen, the latter of which is marked on 
each side with seven clearly defined, deep, angular notches, and 
a blackish linear margin. Six legs, similar in size and general 
features, strongly jointed, and armed with stout claws and hairs, 
come off from the thorax. The head is of a rounded acorn shape' 
and is furnished with two five-jointed antenna, and a pair of large, 
black, prominent eyes. The creature has a grayish or ashy color! 
It varies in length from §'" (1.410 mm.) to H"' (3.174 mm.), 




Fig. XIII.— rKi.irrr.rs Capitis. (25 Diameters ) 
Female. Dorsal surface. 



the female being larger than the male. Upon the back of the 
male is seen a conspicuous and disproportionately large, conical or 
wedge-shaped structure, the penis. The ova, commonly termed 
"nits," are remarkably large (about a quarter of a line), pyriform 
or ovalish, whitish bodies, which are glued securely to the hairs. 
One, two, or more may be deposited on one hair. "According to 
Kiichenmeister,* the young are hatched forth in six days. The 
parasites may be present in small or in large numbers, according 
to the length of time the affection has existed and other circum- 
stances. They are found upon all portions of the head, their 
favorite seats being the occipital region. They are met with either 
upon the surface of the scalp or upon the' hair. The ova are 
found deposited along the shaft of the hair. 

* The Animal and Vegetable Parasites of the Human Body, vol. ii. Syd 
Soc. Trans. London, 1857. 



PEDICULOSIS. 655 

Pediculi capitis are encountered for the most part in children ; 
they are, however, also met with in adults, especially women. 
They are of not infrequent occurrence among the children of the 
poorer classes, especially in public schools. They attack the scalp 
and give rise to considerable irritation, itching, and consequent 
scratching, which is indulged in to such an extent that the scalp 
so n becomes wounded, and oozes a serous or purulent fluid mixed 
with blood, which in time mats the hair and forms into crusts. 
The state of the general health of the patient also influences the 
course of the affection, the parasites, as a rule, causing more mis- 
chief in those who are under bad hygienic influences, improperly 
cared for, and ill nourished, than in the healthy. In those pre- 
disposed to eczema the scalp will, in most cases, show marked 
symptoms of eczema. Together with the pediculi are found the 
ova, or nits, large numbers of which may usually be seen through- 
out the hair, at a distance sometimes resembling the scales of dry 
seborrhoea. They may generally be found in numbers even where 
the pediculi are few. Where the affection has existed for some 
time, the head usually presents a disgusting appearance, and has 
a nauseous odor. The itching in time becomes intolerable ; sleep 
is interfered with, the mind harassed, and the general health, it 
may be, more or less disturbed. 

Pediculosis Corporis. — The parasite here is the pediculus 
corporis, or body louse (termed also, more properly, the pediculus 
vestimenti, or clothes louse). (See Fig. XIV.) As regards its 
anatomical structure, it is very similar to the pediculus capitis, 
although it is considerably larger ; it varies in length from f //r 
(1.157 mm.) to 2" f (4.232 mm.). The female is larger than the 
male. It has an elongate, ovalish shape, with seven well-marked 
indentations on each side of the abdomen, which are less angular 
and more rounded. than in the case of the pediculus capitis. The 
abdomen of the female is broader than that of the male, is more 
deeply notched upon the sides, and possesses a triangular-shaped 
notch at the end. The penis in the male is a remarkably large, 
wedge-shaped structure, situated on the back, and rising from the 
posterior portion of the middle of the abdomen. From the thorax 
spring the legs, three on either side, which are long, jointed, and 
provided with heavy claws and numerous small hairs. The head 
protrudes, is of a rounded acorn shape, and is armed with two 



656 PARASITES. 

hairy, five-jointed antenna?, and prominent eyes. The color of the" 
louse, when devoid of blood, is dirty-white, ashy, or grayish, with 
a dark line around the margin of the abdomen. Its habitat is the 



'■"■ B 





V-v^ 



Fio. XIV. — Tz\>\ (25 Diameters.) 

Female. Dorsal surface. 



clothes covering the general surface; it lives in the garments, re- 
maining upon the skin only long enough to obtain sustenance. 
The ova are deposited in the clothing, usually in the seams, the 
lice being hatched at the end of five or six days. They reproduce 
at the end of eighteen days. Leeuwenhoek, who carefully studied 
their habits, made the calculation that two females might become 
the grandmothers of ten thousand lice in eight weeks. Where 
they are preseut in large numbers, some few may usually be ob- 
served upon the skin, either crawling about or in the act of draw- 
ing blood ; the majority, however, will be found upon the clothes, 
especially about the folds and seams of the undergarments. As 
they move about over the surface or attack the skin, they give rise 
to intensely disagreeable, itching sensations. The patient scratches, 
but obtains no permanent relief; as the parasites multiply, the 
itching becomes so violent that the distress is almost unendurable. 
The scratching is generally severe, and is productive of sera t eh 
lines and marks, excoriations, blood crusts, pigmentation, thick- 
ening of the skin, and pustules with inflammatory bases and more 
or less crusting. 



PEDICULOSIS. 657 

The lesions are characteristic. They are peculiar in being mul- 
tiform ; the scratch marks are here and there long and streaked, 
in other places short and jagged ; the excoriations and blood crusts 
are of all sizes, from a pin-head to a split pea and larger, and 
the pustules irregular in outline. They vary in severity with the 
duration of the affection and the general condition of the patient. 
Upon close inspection, in addition to the scratch marks and other 
secondary symptoms are seen the primary lesions, consisting of 
minute reddish puncta with slight areolae, the points at which the 
parasite has drawn blood. The chief seats of the lesions are the 
back, especially about the scapular region, the chest, abdomen, 
hips, and thighs. Where the affection has existed for months or 
years, as at times happens, a brownish pigmentation of the whole 
skin may take place, the result of long-continued irritation and 
scratching. Pediculosis corporis is encountered for the most part 
in the middle-aged and elderly, although none are exempt from 
its invasion. Children, however, are very seldom attacked. The 
complaint is a common one among the poorer classes of all coun- 
tries, but is far less frequent in this country than abroad. In 
Philadelphia it is comparatively rare. 

Pediculosis Pubis. — The pediculus pubis, or crab louse 
(known also as phthirius inguinalis, phthirius pubis, and mor- 
pio), although having its seat of predilection about the pubes, 
may also infest the axillse, sternal region in the male, beard, 




ry, : 



T W 



Fig. XV.— Pediculus Pubis. ('15 Diameters.) 
Female. Dorsal surface. 



/// 



eyebrows, and even eyelashes. (See Fig. XV.) It is smaller 
than either the head louse or the body louse, measuring from J 
(1.058 mm.) to V" (2.116 mm.). It has a short, broad, flat 

42 



658 PARASITES. 

roundish, or shield-shaped form, with a large, fiddle-shaped head, 
with two stout, five-jointed antenna?, and a pair of small, rather 
inconspicuous eyes. The thorax is short and passes impercepti- 
bly into the abdomen; from the sides of the thorax come off 
six jointed, hairy legs provided with powerful claws; the first 
pair are light, the second and third pair thick and heavy. The 
margin of the abdomen is slightly indented, and armed with 
eight stout, conical or teat-shaped, prehensile feet, each with from 
four to ten bristles. The creature has a yellowish-gray color, and 
is more or less transparent. The female is larger than the male, 
and has a triangular-shaped notch at the termination of the 
abdomen. 

They may be found either crawling about the hairs or adhering 
closely to the surface of the skin. By means of the legs and 
bristles they cling with remarkable tenacity to the parts with 
which they may be in contact The ova are small, whitish or 
yellowish bodies, and are found glued to the hairs, as in the case 
of those of the pediculus capitis. Here and there upon the skin, 
especially about the roots of the hairs, minute reddish particles 
may be seen, being the excrement of the parasite. They infest 
adults chiefly, and occasion symptoms similar to those described 
in connection with the other species. They are usually contracted 
through sexual intercourse; at the same time, it must be stated, 
cases occasionally present themselves in which they have not been 
got in this way, and where, singularly enough, no explanation as 
to the mode of contagion can be suggested. _ The amount of irri- 
tation to the skin which they produce varies ; at times it is severe, 
in other cases it is comparatively insignificant. 

Etiology. — The cause of pediculosis is always to be found in the 
presence of the parasites. All individuals, the robust as well as the 
weakly, are equally liable to be attacked. As in scabies, conta- 
gion, direct or indirect, is the only possible source from which the 
disorder may be contracted.* In this connection the primary 
lesion produced by the parasite, as well as the secondary lesions, 



* Views such as have from time to time heen suggested, pointing to the 
"spontaneous generation" of pediculi, as well as to their having originated 
within the skin or other tissues of the bod}-, it need scarcely be remarked, are 
without foundation. 



PEDICULOSIS. 659 

may be briefly referred to. Considerable attention has been devoted 
to the minute anatomy of the head of the pediculus corporis by 
Landois* and Schiodte.t The latter of these investigators, whose 
studies are the more recent, has arrived at the conclusion that 
pediculi are provided with a sucking apparatus, or haustellum, 
as originally suggested by Swammerdam, and not with a mouth 
and mandibles, as has been commonly supposed. Such being the 
anatomy, it is obvious that the pediculus does not bite, but, insert- 
ing the haustellum into a follicle, obtains blood by a process of 
sucking, producing a lesion which must be regarded in the light of 
a minute hemorrhage. This view is entertained also by Tilbury 
Fox J and others, and is without doubt correct. The secondary 
lesions are usually conspicuous, and are the effects of scratching 
upon the skin. The longer the affection has existed, and the 
more numerous the pediculi are, the more marked will these 
lesions be. The attacks of the parasite, especially in the case of 
pediculi capitis and corporis, bring about a peculiarly irritable 
state of the skin which gives rise to an irresistible desire to 
scratch. As a consequence, the act is indulged in, at first to a 
slight extent, but later to an inordinate degree, so that in the 
course of a few weeks the surface is, as a rule, markedly ex- 
coriated and lacerated. In certain subjects, in addition to the 
excoriations, ecthymatous pustules are produced. The amount of 
pigmentation varies with the duration of the affection, and with 
other circumstances. 

Diagnosis. — The pediculi may always be found, if sufficient care 
be taken to discover them. Frequently they are few, when con- 
siderable research and close observation may be required for their 
detection. » When violent itching exists in any case without marked 
eruption, the possibility of their presence should always be enter- 
tained and an investigation made. 

Pediculosis Capitis. — They are less liable to escape notice here 
than upon other regions of the body. The ova, or nits, which 
may be recognized even at a distance, serve as a diagnostic mark. 

* Zeitschrift far Wissenschaftliche Zoologie, Bd. xiv. and xv. 

f JSTaturhistorisk Tidsskrift, Ser. 3, vol. iii., Copenhagen, 1864-65 ; for 
translation, see Annals and Magazine of Natural History, Ser. 3, vol. xvii., 
1866. 

X Loc. cit., p. 413. 



660 PARASITES. 

The occipital region of the head especially is always more or less 
invaded, and by separating the hairs here they may generally be 
seen without further search, together with scratch marks, serous 
or bloody oozing, matting of the hair, and crusts. The affection 
is often mistaken for vesicular or pustular eczema. In this con- 
nection it is not to be forgotten that eczema is not infrequently 
complicated with pediculosis, and is to be explained in one of two 
ways; either the parasites have brought about the eczema, or, ori 
the other hand, they have been contracted after the eczema, the 
diseased scalp constituting a favorable abode lor them: the former 
course, however, is the more usual. In either case it is important 
to arrive at a conclusion as to the primary affection. 

Pediculosis Corporis. — Pediculi of the body often escape detec- 
tion for the reason that their presence is not suspected. As already 
stated, their habitat is in the clothing, and it i- therefore to the 
undergarments that attention should be directed in looking for 
them. The seams and fold-, especially of the undershirts and 
drawer.-, arc to be examined, for it is here that they will generally 
be found. The extensive excoriations and blood crusts upon the 
shoulder- and back, and the streaks of the finger-nails upon 
various regions, will also aid in the diagnosis; they are, indeed, 
in severe cases characteristic. The minute, reddish, hemorrhagic 
spots, indicating the points where the parasites have drawn blood, 
may also be recognized. Pediculosis of the body has long been 
seriously confounded with two very different diseases, namely, 
prurigo and pruritus. (See these diseases.) Suffice it to say that 
an error in diagnosis cannot take place if the symptoms of the 
diseases in question be borne in mind. The symptoms of scabies 
are so different from those of pediculosis as to call for no remark. 

Pediculosis Pubis. — Itching about the genitalia in either -ex 
should always lead to a careful examination of the parts. The 
diagnosis will in all probability be one of three diseases, namely, 
eczema, pruritus, or pediculosis. The pediculi of this region, on 
account of their transparency and flatness, are at times difficult of 
recognition; they moreover generally adhere closely to the roots 
of the hairs and to the skin, when they present an appearance not 
unlike freckles or dirt specks. The excrement of the parasite will 
be found here and there about the roots of the hairs and on the 
skin, in the form of minute reddish particles. The ova are readily 



PEDICULOSIS. 661 

seen as small, whitish, or yellowish bodies, glued to the hairs. It 
will also be remembered that pediculi pubis not infrequently infest 
the axillae. Existing in either region they usually give rise to 
more or less irritation and annoyance, especially at night; at 
times, however, they cause remarkably little cutaneous disturbance 
and discomfort. 

Treatment. — This is simple, the main object being the destruc- 
tion of the parasites and their ova. The secondary lesions seldom 
demand attention, for, as a rule, they disappear without special 
treatment. The various remedies used comprise the mercurial 
preparations, staphisagria (seeds of Delphinium staphisagria), 
pyrethrum (flowers of Pyrethrum carneum and P. roseum), 
sulphur, sabadilla, cocculus Indicus, tobacco, carbolic acid, and 
petroleum. They are employed in the form of ointment, powder, 
or lotion, as may be deemed most desirable. It need scarcely 
be added that strict regard to cleanliness, both of the person 
and with reference to the clothing and the toilet, should be 
enjoined. 

Pediculosis Capitis. — One of several plans may be employed. 
The head may be well saturated with petroleum, enough being 
used to bathe the scalp, after which a bandage should be applied 
and the dressing kept on through the night. In the morning the 
head should be washed with hot water and soft soap. Where the 
parasites have not been completely destroyed, the petroleum should 
be again applied in the same manner. One or two thorough ap- 
plications suffice. Care should be observed to prevent the oil 
from trickling down the neck. Decoction or tincture of cocculus 
Indicus is also a reliable remedy. Where there is not much ex' 
coriation of the skin, a lotion of corrosive sublimate, from two to 
five grains to the ounce of water, or with alcohol and one of the 
essential oils, is a cleanly and efficacious mode of treatment. Oint^ 
ments are not so advantageously employed as lotions, on account 
of their liability to mat the hair; nevertheless, where the excoria-^- 
tions are extensive, or where eczema is present, they may often be 
applied with benefit. White precipitate, from twenty to sixty 
grains to the ounce, in these cases will be found useful. Oint- 
ments of sabadilla or staphisagria may also be used. The nits 
are to be removed by repeated washings with alkaline or acid 
lotions. Soda or borax washes, soft soap, vinegar, dilute acetic 



662 PARASITES. 

acid, and alcohol, will all prove of service in getting rid of these 
annoying little bodies. It is seldom, if ever, necessary to cut the 
hair. In children, where the ova exist in numbers, there is no 
reason why the hair should not be cut; but in women with long 
hair the operation is unwarrantable. With patience and time 
there is no difficulty in relieving the hair of them. 

Pediculosis Corporis.— In pediculi of the body the first and all- 
important step to be taken is to provide for the clothes, which 
always contain both the parasites and their ova. It is, indeed, the 
clothes (including all the wearing-apparel of the individual), rather 
than the skin, that require treatment. Unless these can be changed 
and cared for, no satisfactory result need be looked for. They are 
to be either boiled or baked at a temperature sufficiently high to 
destroy life. In cases where it is impossible for the patient to have 
the clothes attended to immediately, an ointment of powdered fresh 
staphisagria, two drachms to the ounce, applied freely to the skin, 
has the effect of causing the parasites to disappear. The ointment 
should be made by digesting the powder in hot lard and straining. 
Baths of hot water and soap, and of bicarbonate of sodium, four 
or six ounces to the hath, are also useful in relieving the excoria- 
tions, as well as the itching, which is apt to continue after the para- 
sites have been destroyed. Lotions of carbolic acid, from one to 
three drachms to the pint of water with half an ounce of glyce- 
rine, will also be found useful in allaying the irritability of the 
skin. But, to repeat, it is to the clothes that the attention should 
be devoted. The undergarments should in all cases be changed 
frequently for the first few days, and immediately boiled. They 
should be carefully examined from time to time, and if a single 
pedieulus be found they should be submitted again to treatment j 
unless these precautions receive attention the parasites are very apt 
to reappear. The lack of scrutiny upon this point will account 
for the cases of chronic pediculosis of the body, occasionally en- 
countered, who wander about laboring under the impression that 
they never can be permanently relieved. Patients should be in- 
formed as to the nature of their affection, and assured further that 
by heed to the treatment a short time will suffice for complete 
relief. 

Pediculosis Pubis.— Any of the ointments or lotions already 
spoken of may be used. The tincture of cocculus Indicus, full 



CIMEX LECTULARIUS. 663 

strength or diluted, and corrosive sublimate lotion, will be found 
clean and effectual remedies. Infusion of tobacco will also answer 
the purpose. The parts should be washed twice daily with soft 
soap and water, and the remedy applied for some days after the 
pediculi have been destroyed, to insure complete destruction- of the 
ova. White precipitate ointment and mercurial ointment are well- 
known and effectual remedies which may be mentioned. 

Prognosis. — After the remarks which have been made, little need 
be said concerning the termination of the disease. It is always 
satisfactory, provided the patient is able to follow the instructions. 
It is here that the difficulty at times arises in relieving certain 
cases, circumstances not permitting of the treatment. Instances 
of pediculophobia are occasionally encountered, sometimes among 
intelligent persons, who though cured believe that they still have 
the disease ; others, perhaps the victims of pruritus, imagine them- 
selves infested by pediculi.* 

Cimex Lectularius, Acanthia Lectularia, or Common 
Bed-bug. — This insect is not infrequently the cause of mischief 
upon the skin. It is found in beds, about the joints, grooves, 
and crevices, and in the bedding and bedclothes, about the seams 
and folds ; also in the cracks of old floors and walls, wall-paper, 
and furniture, and in other like places. It lives upon human 
blood. It is very tenacious of life, and is said to be able to 
live without food for a very long period. It possesses a strong 
and offensive, cinnamon-like odor, which is particularly noticeable 
when it is crushed. It exists almost universally, although, ac- 
cording to K lichen meister, it is not found in South America, 
Australia, or the Polynesian islands. The cutaneous lesion which 
it produces is of the nature of an urticarial wheal, consisting of a 
circumscribed, slightly raised, split-pea sized, erythematous spot 
with a whitish centre, and at times attended with considerable 
swelling. The lesion is a hemorrhage, which remains as a reddish 
point after the wheal has subsided. The sensation accompanying 

* Pigeon, or hen, lice (Dermanyssus avium) may also occasionally infest 
the human skin, as in the case of a woman reported by Dr. Goldsmith, where 
they resided in the sweat pores, but were made to appear on the surface by 
induced excessive sweating. Other cases are also referred to. (New York 
Med. Rec, Oct. 29, 1881.) 



664 PARASITES. 

the act of drawing blood is that of a very slight prick, followed 
in a few minutes by decided itching and burning almost identical 
with that of urticaria. Ssratching usually takes place, followed 
at times, especially in children, by excoriations. 

Among the lower classes in overcrowded, old frame houses, 
these pests often exist in great numbers and at times occasion con- 
siderable suffering, especially in children. The bed-bug is said to 
have a foe in the cockroach ; also, according to Prof. Riley,* in the 
"two-spotted corsair" (Pirates biguttatus) met with in bed- infested 
with bed-bugs in southern Illinois, and in Louisiana, Texas, Cali- 
fornia, and Mexico. According to the same authority, the "blood- 
sucking cone-nose," or "big bed-bug" (Conorhinus sanguisuga), 
has been (bund in \h'<\> in southern Illinois and ( Hiio, bill it prob- 
ably doe- not occur farther north. This species is said to produce 
lesions followed by severe inflammation of the skin. The bites 
of the bed-bug may be relieved by lotions containing alcohol, car- 
bolic acid, vinegar, dilute acetic acid, corrosive sublimate, lead- 
water, water of ammonia, and similar remedies, sponged upon 
the parts. The besl preventives againsl bugs in beds and other 
haunts are corrosive sublimate and pyrethrum powder. 

Pulkx [rbitans, or Common- Flea. — This little pes! is 
found universally, especially in hot and warm climate-. Although 
it provokes no serious cutaneous disturbance, it i- neverth 
in certain part- of the work], especially in tropical countries, the 
source of considerable discomfort to man. The lesion which it 
produces is an erythematous spot with a minute, central, darker, 
hemorrhagic point. Flea-bites may be mi-taken for purpura sim- 
plex; the areola with which the central point of the bite is Bur- 
rounded will, however, suffice to establish the diagnosis. 

Culex, Gnat, or Mosquito. — According to Packard, the typi- 
cal species of the genu- culex, to which the mosquito belongs, i- 
( lulex Pipiens. < >ver thirty North American species of this genus 
have been described in various works. The mosquito is common 
to almost every section of our country, and is not infrequently the 
source of considerable irritation upon the skin, causing wheals, 

* American Entomologist, vol. i. j>. 85. 



Ixodes. 665 

varying in their features with the sensitiveness of the skin. The 
itchiness of the lesion is best relieved with ammonia-water. The 
midge and black fly of the Northern States and Canada (both 
species of Simulium) also give rise to annoyance during the early 
summer months, occasioning lesions similar to those of the mos- 
quito. 

Ixodes, or Wood-Tick. — Ticks belong to the order Acarina. 
They are described by Packard * as being " mites of gigantic size 
with bodies of a leathery consistence. The mandibles are saw- 
like, being covered towards the end with teeth, with from two to 
four terminal hooks, and, with the large spatulate, dentate ' glos- 
soide' of the maxilla?, form a beak which the tick pushes into the 
skin of its host." There are several species met with in our woods 
which are liable to attach themselves to the human skin. Packard 
describes Ixodes unipunctata, which has been found on man in 
Pennsylvania and in Massachusetts. The common cattle tick, 
Ixodes bovis, met with in the Western States and in Central 
America, according to the same authority, is allied to the European 
Ixodes ricinus. They insert their proboscis and head deeply into 
the tissues, and suck blood until they not infrequently swell up to 
many times their natural size. They should never be extracted 
with violence, but should be induced to relinquish their firm hold 
upon the skin by dropping upon them some oily substance, as olive 
oil or one of the essential oils. 

* Guide to the Study of Insects, New York, 1878. 



INDEX. 



Absorption by the skin, 18. 
Acanthia lectularia, 663. 
Acarus autumnalis (note), 648. 

folliculorum, 651. 

scabiei, 642. 
Achorion Schonleinii, 596. 
Achroma, acquired, 432. 

congenital, 430. 
Acne, 268. 

artificialis, 271. 

atrophica, 270. 

cachectic, 272. 

cornea, 270. 

diagnosis of, 273. 

disseminata, 268. 

etiology of, 271. 

hypertrophica, 270. 

indurata, 270. 

papulosa, 270. 

pathology of, 272. 

prognosis of, 280. 

punctata, 270. 

pustulosa, 270. 

symptoms of, 268. 

treatment of, constitutional, 274. 
local, 276. 
Acne albida, 131. 

boutonneuse, 268. 

bromine, 271. 

iodine, 271. 

mentagra, 288. 

vulgaris, 268. ^" 
Acne rosacea, 281. 

diagnosis of, 285. 

etiology of, 283. 

pathology of, 284. 

prognosis of, 288. 

symptoms of, 281. 

treatment of, 286. 
Acne sebacea, 115. 

sebacee, 115. 

syphilitica, 523. 

tar, 271. 

varioliformis, 377. 



Acne-form syphiloderm, 523. 
Acquired achroma, 432. 
leucasmus, 432. 
leucopathia, 432. 
piebald skin, 432. 
Acrochordon, 462. 

Acuminated pustular syphiloderm, 
small, 522. 
large, 523. 
Acute general dermatitis, 328. 
Acuteness of disease, in diagnosis, 90. 
Addison's disease, pigmentation of 

skin in, 371. 
Adipose tissue, 29. 
Age, in diagnosis, 88. 

influence of, in etiology, 70. 
Ainhum, 490. 
Albinism, 430. 
Albinismus, 430. 
Albinoes, 431. 
Aleppo boil, 333. 
bouton, 333. 
evil, 333. 
Algidite progressive, 414. 
Algor progressivus, 4l4. 
Alopecia, 444. 

congenital, 444. 
idiopathic premature, 445. 
senile, 445. 
simplex, 445. 

symptomatic premature, 446. 
syphilitic, 446. 
treatment of, 447. 
Alopecia areata, 448. 

diagnosis of, 451. 
etiology of, 450. 
pathology of 450. 
prognosis of, 454. 
symptoms of, 448. 
treatment of, 452. 
Alopecia circumscripta, 448. 
Alphos, 304. 

American harvest mite, 648. 
Anaemia, 80. 
Anaesthesia, 591. 
dolorosa, 592. 

667 



Anaesthetic leprosy, 404. 
Analgesia, 591. 
Anatomical tubercle, 338. 
Anatomy and physiology of the skin, 

17. 
Anatomy of the bloodvessels, 31. 
corium, 26. 
epidermis, 20. 
hair-follicle, 47. 
hairs, 44. 
lymphatics, 31. 
muscles, 37. 
nails, 51. 
nerve-, 33. 

Pacinian corpuscles, 34. 
pigment, 37. 
sebaceous glands, 42. 
skin. 17. 

subcutaneous connec- 
tive tissue, 20. 
sweat glands, 38. 
tar-tile corpuscles, 33. 
Angioma caver nosun 
lipomatodes, 564. 
lobular 
simplex, 563. 
Anidrosis, 139. 

treatment of, 1 1". 
Aniline, dermatitis from, 348. 
Anodynia, 591. 

AnomalisB secretionis, 111, 116. 
Anthrax. 334. 
diagnosis of, 
etiology of, 
pathology ol 
prognosis o 
symptoms of, 334. 
treatment of, 
Aperients, in treatment. 102. 
Aplasie lamineuse pn i 

of the skin, 20. 
Area Celsi, 448. 
Argyri 

Army itch, 641. 
Arnica, dermatitis from tincture of, 

341.343. 
Arrectores pili muse: 
Arsenic, dermatitis from, 347. 

in treatmei 
Artificial acne. 271. 
eruptions. 344. 
Asiatic pill-. 315. 
Atheroma, 133. 
Atrophia cutis. 437. 
general, 438. 
lineari-. 442. 
propria. 437. 
pilorum propria. 454. 
Atrophite, 113, 430. 



Atrophic lines and spots, 442. 
Atrophies, 113, 430. 
Atrophy, 83. 

of the face, unilateral, -413. 

hair, 454. 

hair pigment, 435. 

nail, 457. 

skin, 437. 
senile. 443. 
Atropia, dermatitis from, 347. 
Aussatz. der, 402. 



Baldness, idiopathic premature, 445. 

of old age, 4 15. 
Bandages, in treatment, 104. 
Barbadoes leg, 415. 
Barber's itch, 623. 
Bartfinni 

Bath, continuous, 2-56. 
Baths, in treatment, 102. 
Bed-bug, big, 664. 

common, I 
Bed-on-, 346. 
Belladonna, dermatitis fron 
Biskra bouton, 333. 
Black fly, 665. 

Blanching of the hair, sudden, 435. 
Blaschen, 56. 
Blasen, 57. 

Blasenausschlag, 249. 
Blebs, 57. 

Bleeding stigmata, 
Blood-sucking cone-nose, 66 1. 
Bloodvessels, 31. 
Bloody sweat, 366. 
Blutfleckenkrankheit, 300. 
Blutschwar, 330. 
Body louse, 656. 
Boil'. 330. 

Aleppo. 333. 

Delhi. 333. 
Borken, 61. 
Bot fly, 651. 
Bouton, Aleppo, 333. 

Biskra, 333. 
Brandschuar. 
Breeze fly, 651. 
Broad, condyloma. 51 I. 
Bromides, dermatitis from, 3-18. 
Bromidrosis. 140. 

pedum, 141. 

symptom- of, 140. 

treatment of. 142. 
Bromine acne. 271. 

dermatitis from, 348. 
Bucnemia tropica, 415. 



INDEX. 



669 



Bullae, 57. 
Bulles, 57. 
Bullous syphiloderm, 528. 



C. 



Cachectic acne, 272. 
Calculi, cutaneous, 132. 
Cullositas, 382. 

etiology of, 382. 

pathology of, 383. 

symptoms of, 382. 

treatment of, 383. 
Callosity, 382. 
Callus, 382. 
Calvities, senile, 445. 
Cancer, connective tissue, 547. 

en cuirasse, 547. 

epithelial, 548. 

fibrous, 547. 

hard, 547. 

scirrhous, 547. 
Cancroid, 548. 
Cancroide, 548. 
Canities, 435. 

Cannabis indica, dermatitis from, 350. 
Carbolic acid, in treatment, 101. 
Carbuncle, 334. 
Carbunculus, 334. 
Carcinoma, 547. 

epitheliale, 548. 

lenticulare, 547. 

melanodes, 548. 

pigmentodes, 548. 

tuberosum, 547. 
Cauliflower excrescence (note), 389. 
Cause of the disease, in treatment, 

96. 
Causes of disease, external, 75. 
internal, 72. 
Caustics, in treatment, 106. 
Chaps, 177. 
Charbon, 339. 

Cheiro-pompholyx, 248, 329. 
Cheloide, 458. 
Chigger, 649. 
Chigoe, 649. 
Chloasma, 370. 

diagnosis of, 373. 

etiology of, 372. 

pathology of, 373. 

symptoms of, 370. 

treatment of, 373. 

uterinum, 371. 
Chloasma (Wilson), 629. 
Chloral, dermatitis from, 350. 
Chorionitis, 400. 
Chromidrosis< 142. 



Chromidrosis, pathology of, 143. 

symptoms of, 142. 

treatment of, 143. 
Chronicity of disease, in diagnosis, 

90. 
Chrysarobin, 320. 

Chrysophanic acid, ointment of, 320. 
Cicatrices, 64. 
Cimex lectularius, 663. 
Cingulum, 231. 
Claret stain, 563. 
Classification, 111. 
Clavus, 383. 

etiology of, 384. 

pathology of, 384. 

symptoms of, 383. 

treatment of, 384. 
Climate, influence of, in etiology, 71. 
Clothes louse, 656. 

Clothing, dermatitis from poisonous, 
343. 

influence of, in etiology, 75. 
Cod-liver oil, in treatment, 97. 
Colloid degeneration of the skin, 467. 
Colloid-milium, das, 467. 
Color of disease, in diagnosis, 91. 

in symptomatology, 
68. 
Colored sweat, 142. 
Columnse adiposse, 29. 
Comedo, 128. 

diagnosis of, 129. 

etiology of, 129. 

pathology of, 129. 

prognosis of, 131. 

symptoms of, 128. 

treatment of, 130. 
Common bed-bug, 663. 

flea, 664. 

wart, 387. 
Compound papilla?, 27. 
Conditions influencing disease, 70. 
Condylom, spitze (note), 389. 
Condyloma, broad or flat, 514. 

pointed (note), 389. 

subcutaneum, 377. 
Cones fibreux, 29. 

Configuration of disease, in sympto- 
matology, 66. 
Congenital achroma, 430. 

alopecia, 444. 

elephantiasis, 418. 

leucasmus, 430. 

leucoderma, 430. 

leucopathia, 430. 

syphilis, 529. 
Connective tissue, subcutaneous, 29. 
Conorhinus sanguisuga, 664. 
Constitutional diseases, influences of, 
in etiology, 72. 



670 



INDEX. 



Constitutional disturbance, in diag- 
nosis, 88. 

treatment, 97. 
Contagion, influence of, in etiology, 76, 
Contagious impetigo, 297. 

molluscum, 377. 
Continuous bath, 256. 
Copaiba, dermatitis from, 351. 
Cor, 383. 

Coralline, dermatitis from, 343. 
Corium, 26. 

papillary layer, 27. 

pars papillaris, 27. 

pars reticularis, 28. 

reticular layer, 28. 
Corn, 383. 

hard. 384. 

soft, 384. 
Corne de la peau, 385. 
Corneous layer of epidermis, 21. 
Cornu cutaneum, 385. 

etiology of, 386. 

pathology of, 387. 

symptoms of, 385. 

treatment of, 387. 
Cornu humanum, 385. 
Corpuscles of Bleissner, 33. 

of Vater, 34. 

of AVa-ner, 33. 

Pacinian, 34. 

tactile, 33. 
Corsair, two-spotted, 664. 
Cosmetics, dangerous (note), 279. 
Coster's paste, 621. 
Couperose, 281. 
Crab louse, 659. 

Croton oil. dermatitis from, 344. 
Croutes, 61. 
CrUSta laetea, 173. 
Crustffl, 61. 

Crusted ringworm, 593. 
Crusts, 61. 

Cubebs, dermatitis from, 3-31. 
Culex, 664. 

pipiens. 664. 
Cuniculus, 638. 
Curette, the dermal, 484. 
Cutaneous calculi, 132. 

cysts, 570. 

horn, 385. 

tumors, 60. 
Cuticula, 20. 
Cuticle, 20. 
Cutis, 26. 
Cutis anserina, 37. 
Cutis pendula, 420. 
Cutis tensa chronica, 400. 
Cutis unctuosa, 115. 
Cutis vera, 26. 
Cvsticercus cellulosa?. 650. 



D. 



Dandriff, 115. 
Dandruff, 115. 
Dartre rongeante, 475. 
Decrepitude infantile, 414. 
Defluvium capillorum, 446. 
Defeneration of the skin, colloid, 467. 
Delhi boil, 333. 
Demodex folliculorum, 651. 
Dentition, influence of, in etiology, 74. 
Depilatories, 426. 
Derma, 26. 
Dermal curette, 484. 
Dermalgia, 577. 
Dermalgie, 577. 

Dermanyssus avium (note), 663. 
Dermatalgia, .377. 
diagnosis of, 678. 
etiology of, 578. 
pathology of, 578. 
symptoms of, 577. 
treatment pi 
Dermatite exfoliatrice generalisee 

(note), 
Dermatitis, 840. 
calorica, 344. 
gangrenosa, 3 1 1. 
medicamentosa, 346. 
traumatica, 3 l". 
venenata, 341. 
Dermatitis from ai - nic, ; : 17. 

belladonna, atropia, 347. 
bromine, bromides, 348. 
cannabis Indica, 
chloral, 350. 
copaiba, 851. 
croton oil. 31 1. 
cubebs, 851. 
digitalis, 851. 
iodine, iodides, 351. 
mercurial ointment, 344. 
mercury, 354. 
opium, morphia, 354. 
phosphoric acid, 
quinine, 355. 
salicylic acid, 356. 
santonine, 356. 
stramonium. 336. 
strychnia, 337. 
turpentine, 337. 
Dermatitis contusiformis, 156. 
Dermatitis exfoliativa, 328. 
Dermatitis papillaris capillitii, 392. 
Dermatoh-.-i~, 420. 

pathology of, 422. 

symptoms of, 420. 

treatment of. 422. 

Dermatomyoma, -373. 

Dermatosclerosis, 400. 



671 



Dermatosyphilis, 506. 
Desquamative scarlatiniforrn erythe- 
ma, 328. 
Diachylon ointment, 201. 
Diagnosis, 86. 

acuteness of disease in, 90. 

age in, 88. 

chronicity of disease in, 90. 

color of disease in, 91. 

constitutional disturbance in, 88. 

distribution of the disease in, 91. 

examination in, 87. 

extent of disease in, 91. 

general features of the disease in, 
90. 

habits in, 89. 

individual lesions in, 91. 

inspection in, 87. 

light in, 86. 

occupation in, 90. 

sex in, 88. 

temperament in, 89. 

temperature of the apartment in, 
86. 
Digitalis, dermatitis from, 351. 
Discoloration, 54. 

of the skin, 375. 
Disorders of internal organs, influ- 
ence of, in etiology, 73. 
Disorders of secretion, 111, 115. 
Dissection tubercle, 338. 
Dissection wounds, 338. 
Distribution of disease, in general 
symptoms, 66. 

in diagnosis, 91. 
Diuretics, in treatment, 102. 
Dracunculus, 649. 
Driving in eruptions, 94. 
Dusting powders, in treatment, 104. 
Dysidrosis, 247. 



E. 

Ecchymomata, 359. 
Ecchymoses, 359. 
Ecthyma, 300. 

diagnosis of, 302. 

etiology of, 301. 

pathology of, 302. 

prognosis of, 304. 

symptoms of, 300. 

treatment of, 303. 
Ecthyma syphiliticum, 524. 
Ecthyma-form syphiloderm, 524. 
Eczem, 169. 
Eczema, 169. 
Eczema, 169. 

acutum, 178. 

ani, 219. 



Eczema articulorum, 218. 
artificial, 182. 
aurium, 217. 
barbae, 216. 
capitis, 210. 
chronicum, 178. 
constitutional causes of, 180. 

treatment of, 193. 
crurum, 222. 
diagnosis of, 186. 
diagnosis of, from artificial in- 
flammations, 192. 

erysipelas, 188. 

erythema simplex, 188. 

herpes, 189. 

lichen ruber, 190. 

pemphigus, 189. 

pityriasis rubra, 190. 

psoriasis, 189. 

scabies, 191. 

scarlatina, 188. 

seborrhcea, 189. 

sycosis, 191. 

syphilis, 192. 

tinea circinata, 191. 

tinea favosa, 191. 

urticaria, 188. 
erythematosum, 171. 
etiology of, 178. 
faciei, 214. 
fissum, 177. 
genitalium, 218. 
impetiginosum, 173. 
intertrigo. 182, 220. 
labiorum, 215. 
local causes of, 181. 

treatment of, 196. 
acute, 197. 
chronic, 202. 

varieties of, their diagnosis 
and treatment, 209. 
madidans, 175. 
mammarum, 221. 
manuum, 224. 
mercuriale, 182. 
oedematosum, 172. 
palmarum et plantarum, 224. 
palpebrarum, 215. 
papillqmatosum, 178. 
papillosum, 174. 
pathology of, 183. 
prognosis of, 209. 
pustulosum, 173. 
rimosum, 177. 
rubrum, 175. 
sclerosum, 178. 
solare, 182. 
squamosum, 176. 
symptoms of, 169. 
treatment of, 193. 



672 



INDEX. 



Eczema umbilici, 222. 

unguium, 226. 

universale, 210. 

verrucosum, 178. 

vesiculosum, 172. 
Eczema marginatum, 191, (note) 603. 
Eczema-form syphiloderm, 524. 
Eczema of the nipple, 221. 
Electricity, in treatment, 108. 
Elephant "leg, 415. 
Elephantiasis, 415. 

congenital, 418. 

diagnosis of, 419. 

etiology of, -11 7. 

pathology of, 418. 

prognosis of, 420. 

symptoms of, 415. 

treatment of, 419. 
Elephantiasis Arabum, 415. 
Elephantiasis GrsBCorum, 492. 

telangiectodes, 122. 
Encysted tumor, 133. 
Endemic verrugas, 503. 
English Bickness, 242. 
Entozoon folliculorum, 651. 
Ephidrosis, 184. 

cruenta, 366. 

discolor, 142. 
Epidermic sea 
Epidermis, 20. 

granular layer of, 22. 

horny layer of, 21. 

mucous layer of, 23. 

Btratum corneum of. 21. 

Btratum granulosum of, 22. 

stratum lucidum of, 22. 

Btratum mucosum of, 23. 
Epithelial cancer, "'4 s . 
Epithelialkrebs, 548. 
Epithelial molluscum, 377. 
Epithelioma, ">l s . 

deep-seated, or infiltrating va- 
riety of, 550. 

diagnosis of, 555. 

etiology of, 552. 

papillary variety of, 551. 

pathology oi 

prognosis of, 558. 

superficial, or tiat variety of, 548. 

symptoms < 

treat 11 lent of, 556. 
Epithelioma molluscum, 377. 
Equinia, 
Erbgrind, 593. 
Ereetores pili, 37. 
Eruption. 65. 
Eruptions, artificial. 346. 

medicinal. 346. 
Erythema, 54. 
Erythema centrifuge. 470. 



Ervthema gangrenosum, feigned, 

* 346. 
Erythema intertrigo, 150. 

etiology of, 150. 
symptoms of, 150. 
treatment of, 1-31. 
Erythema multiforme, 152. 
annulare, 153. 
diagnosis of, 155. 
etiology of, 154. 
iris, 153. 

marginatum, 153. 
papulosum, 153. 
pathology of, 154. 
prognosis of, 156. 
symptoms of, 152. 
treatment of, 155. 
tuberculosum, 153. 
Erythema nodosum, 156. 

diagnosis of, 157. 
etiology of, 157. 
pathology of. 157. 
prognosis of, 158. 
symptoms of. 156. 
treatment of, 158. 
Erythema simplex, 148. 

diagnosis of. 149. 
from caloric, 148. 
poisons, 1 18. 
traumatism, 148. 
idiopathic, 148. 
symptomatic, 149. 
symptoms o 
treatment of, 1 19. 
Erythematous eczema, 171. 
Byphilide, 509. 
bj philoderm, 509. 
Erytheme noueux, 156. 
Esthiomene, 475. 
Etiology, 70. 
age in. 70 
climate in. 71. 
clothing in. 75. 
conditions influencing disease in, 

70 
constitutional diseases in, 72. 
contagion in. 76. 
dentition in. 7 I. 
disorder- of internal on 

7:;. 
external causes in, 75. 
food in, 73. 
hereditability in. 72. 
internal causes in, 72. 
irritants in, 75. 
medicine in, 74. 
occupation in. 75. 
predisposition in, 72. 
pregnancy in. 7 1. 
scratching in, 76. 



INDEX. 



673 



Etiology, seasons in, 71. 

sex in, 71. 

uncleanliness in, 76. 

vaccination in, 74. 
Evil, Aleppo, 333. 
Examination of patient, in diagnosis, 

87. 
Exanthematous syphilide, 509. 
Excessive sweating, 134. 
Excoriationes, 62. 
Excoriations, 62. 

neurotic, 366. 
Excrescence, cauliflower (note), 389. 
Exfoliative dermatitis of nursing- 
children (note), 329. 
Exsudationes, 112, 152. 
Extent of disease, in diagnosis, 91. 
External causes of disease, 75. 
Exudation, 81. 
Exudations, 152. 



Earcv, 339. 

Favus, 593. 

Eebris urticata, 158. 

Feigned diseases of the skin, 344. 

Feigned erythema gangrenosum, 346. 

Feigned pemphigus (note), 255. 

Feuergiirtel, 231. 

Feuermal, 563. 

Fibroma fungoides, 562. 

lipomatoses, 464. 

molluscum, 461. 
Fibromyoma, 575. 
Fig wart (note), 389. 
Filaria medinensis, 649. 
Filaria sanguinis hominis, 417. 
Finnen,268. 

Fischschuppenausschlag, 393. 
Fish-skin disease, 393. 
Fissures, 63. 
Flat condyloma, 514. 
Flat pustular syphiloderm, small, 524. 
large, 524. 
Flea, common, 664. 
Flecke, 54. 
Fleckenmal, 376. 
Fluxus sebaceus, 115. 
Fly, black, 665. 

bot, 651. 

breeze, 651. 

gad, 651. 
Follicular elevations, 131. 

tumor, 133. 
Folliculitis barbse, 288. 
Food, influence of, in etiology, 73. 

in treatment, 97. 



Foot, perforating ulcer of, 491. 
Fragilitas crinium, 455. 
Fragility of the hair, 455. 
Frambcesia, 503. 
Freckle, 368. 
Fressende flechte, 475. 
Fungoid diseases of the skin, 562. 
Fungus foot of India, 490. 
Furoncle, 330. 
Furuncle, 330. 
Furunculosis, 330. 
Furunculus, 330. 

diagnosis of, 332. 

etiology of, 331. 

pathology of, 331. 

prognosis of, 333. 

symptoms of, 330. 

treatment of, 332. 



G. 



Gad-fly, 651. 

Galactidrosis, 145. 

Gale, 627. 

Galvano-cautery, the, 484, 567. 

Gefassmal, 563. 

Gangrene of the skin, 344. 

General atrophia cutis, 438. 

General considerations, 17. 

General exfoliative dermatitis, 328. 

General features of the disease, in 

diagnosis, 90. 
General idiopathic papilloma, 392. 
General symptoms, 65. 
Gescbwiire, 64. 
Giant urticaria, 161. 
Glanders, 339. 
Glands, sebaceous, 42. 

sweat, 38. 
Glandulse sebiparse, 42. 

sudorifera?, 38. 
Glossy skin, 437. 
Glycerole of lead, 208. 
Gnat, 664. 
Gneis, 115. 
Goose-flesh, 37. 
Goudron de Guyot, 204. 
Granular layer of epidermis, 22. 
Graying of the hair, sudden, 435. 
Grayness of the hair, 435. 
Great mortality (note), 242. 
Greisenhaftigkeit der kinder, 414. 
Grutum, 131. 
Guinea worm, 649. 
Gumma, 527. 
Gummatous syphilide, 527. 

syphiloderm, 527. 
Gummy tumor, 527. 



43 



674 



IXDEX. 



Gtirtelkrankheit, 231. 
Gutta rosacea, 281. 
rosea, 281. 



H. 



Habits, in diagnosis, 89. 
Hsematidrosis, 365. 
Hsemidrosis, 365. 
Haemorrhage, 112. 
Hsemorrhagiae, 112. 359. 
Hair, atrophy of, 454. 
fragility of. 455. 
hypertrophy of, 422. 
sudden graving of, 435. 
Hair-follicle, 47. 
Hairs, 44. 
Hairy people, 423. 
Harvest bug (note), 648. 
Harvest mite, American, 648. 

irritating, 648. 
Hautabschurfungen, 62. 
Hauthorn, 385. 
Hautsehrunden. 63. 
Hautsclerem, 400. 
Head louse, 654. 
Heat, prickly, 242. 
Hemiatrophia facialis, 418. 
Hemorrhage, 82. 
idiopathic, 
symptomatic, 359. 
Hemorrhages, 1 12, 359. 
Hemorrhagise, 112. 
Hemorrhcea petechialis, 360. 
Hen lice, 663. 

Hereditability, influence of, in eti- 
ology, 72. 
Hereditary syphilis, infantile, 529. 
Herpes, 227. 
Herpes circimr 

bullosus (note), 230. 
circine, 602. 
Herpes contagiosus varioliformis 

(note), 298. 
Herpes esthiomenos, 475. 
Herpes facialis, 227. 
labial: 

praeputialis, 228. 
progenitalis, 
symptoms of, 227. 
treatment of, 230. 
Herpes gestation is, 230. 
Herpes impetiginiformis, 254. (note) 

297. 
Herpes iris, 239. 

diagnosis of. 241. 
etiology of. 240. 
pathology of, 240. 
prognosis of. L'41. 



Herpes iris, symptoms of, 239. 

treatment of, 241. 
Herpes tonsurans, 612. 
Herpes tonsurant, 612. 
Herpes zoster, 231. 

diagnosis of, 237. 
etiology of, 235. 
pathology of, 235. 
prognosis of, 239. 
symptoms of, 231. 
treatment of, 237. 
Herpetiform syphilide (note), 522. 
Hirsuties, 422. 

gestationis, 424. 
Hives 158. . 

Homines pilosi, 423. 
Homo hirsutus, 42-!. 
Honey-comb ringworm, 593. 
.Honi, cutaneous', 385. 
Horny excrescence, 385. 
layer of epidermis, 21. 
tumor, 385. 
Huhnerauge, 383. 
Hydroa, 239. 

vesiculeux, 239. 
Hydroadenitis, 331. 
Hydrosis, L34. 
Hygiene, in treatment, 97. 

a ■mia, 79 
Hyperemia;, 111, 147. 
Hyperemias, 111, 1-17. 
HypcraBsthesia, 570. 
Hyperidrosis, 184. 
diagnosis of. 187, 
etiology of. 136. 
pathology of, 137. 
prognosis of. 139. 
symptoms of. 184. 
treatment of, 187. 
Hypertrichiasis, 122. 
Hypertrichosis, 122. 
Hypertrophic, 1 12, 368. 
Hypertrophic papule-, .",14. 
Hypertrophies, 112, 368. 
Hypertrophy, 83. 
Hypertrophy of the hair, 422. 

etiology of, 424. 
treatment of. 425. 
Hypertrophy of the nail, 427. 

treatment of, 428. 



I. 

Ichthyose. 303. 
Ichthyosis 

diagnosis of, 397. 
etiology of. 396. 
hystrix, 394. 
nigricans, 395. 



675 



Ichthyosis, pathology of, 396. 

prognosis of, 398. 

simplex, 393. 

symptoms of, 393. 

treatment of, 397. 
Ichthyosis congenita, 393. 

sebacea, 115. 

vera, 393. 
Ichthyosis hystrix congenita, 392. 
Idiopathic diseases, 70. 
Idiopathic hemorrhage, 359. 
Idrosis, 134. 
Ignis sacer, 231. 
Impetigo, 293. 

diagnosis of, 296. 

etiology of, 294. 

pathology of, 294. 

symptoms of, 293. 

treatment of, 296. 
Impetigo contagiosa, 297. 

diagnosis of, 300. 
etiology of, 298. 
pathology of, 299. 
prognosis of, 300. 
symptoms of, 297. 
treatment of, 300. 
Impetigo herpetiformis, 254, 296. 
Impetigo syphilitica, 524. 
Impetigo-form syphiloderm, 524. 
Individual lesions of disease, in diag- 
nosis, 91. 
Induratio telae cellulosse neonatorum, 

414. 
Infantile syphilis, hereditary, 529. 
Inflammation, 80. 

product of, 81. 
Inflammations, 112, 152. 
Inflammatory fungoid neoplasm, 560. 
Inspection of patient, in diagnosis, 87. 
Integumentum commune, 17. 
Internal causes of disease, 72. 
Intertrigo, 150,' 182, 220. 
Iodide of potassium, in treatment, 101. 
Iodides, dermatitis from, 351. 
Iodine acne, 271. 

dermatitis from, 351. 
Iron, in treatment, 98. 
Irritants, influence of, in etiology, 75. 
Irritating harvest mite, 648. 
Itch, 627. 

army, 641. 

mite, 642. 
Ixodes, 665. 



Jigger, 649. 
Juckblattern, 262. 



Kelis, 458. 

Keloid, 458. 

Keloid, cicatricial, 459. 

diagnosis of, 460. 

etiology of, 459. 

pathology of, 460. - 

prognosis of, 461. 

spontaneous, 459. 

symptoms of, 458. 

treatment of, 461. 
Keloid of Addison, 408. 

of Alibert, 410. 
Kelos, 458. 

Keratosis pigmentosa, 388. 
Keratosis pilaris, 399. 

diagnosis of, 399. 

symptoms of, 399. 

treatment of, 400. 
Kerion, tinea, 622. 
Kleienflechte, 629. 
Knollen, 60. 
Knotchen. 55. 
Knoten, 60. 
Kriitze, 627. 
Krusten, 61. 
Kupferrose, 28. 
Kupfrige gesicht, das, 281. 



Land scurvy, 363. 

Lanugo, 44. 

Lausesucht, 653. 

Leichdorn, 383. 

Lenticulse nigrse, 369. 

Lenticular papular syphiloderm, 512. 

Lentigo, 368. 

etiology of, 369. 

pathology of, 370. 

symptoms of, 368. 

treatment of, 370. 
Leontiasis, 492, 494. 
Lepra, 304, 492. 

ansesthetica, 494. 

diagnosis of, 499. 

etiology of, 495. 

maculosa, 493. 

mutilans, 495. 

pathology of, 498. 

prognosis of, 503. 

symptoms of, 492. 

treatment of, 501. 

tuberculosa, 493. 

tuberosa, 494. 
Lepra alphos, 304. 
Lepra Arabum, 492. 
Lepre, la, 492. 



076 



INDEX. 



Leprosy, 492. 

ansesthetic, 494. 
Lombardian, 505. 
tubercular, 493. 
Leptus, 648. 

Americanus, 648. 
autumnalis (note), 648. 
irritans, 648. 
Lesions of the skin, 54. 
color of, 68. 
configuration of, 66. 
distribution of, 66. 
locality of, 67. 
primary, 54 
secondary, 61. 
symmetry of, 67. 
Leucasmus, acquired, 432. 

congenital, 430. 
Leucoderma, acquired, 432. 

congenital, 430. 
Leucopatbia, acquired, 432. 

congenital, 430. 
Lice, (154, 663. 
Lichen pilaris, 399. 
Lichen planus, 257, 260. 
Lichen ruber, 257. 

acuminatum. 257. 
diagnosis of, 261. 
etiology of, 259. 
pathology of, 200. 
planus, 257. 
prognosis of, 261. 
symptoms of, 257. 
treatment of, 261. 
Lichen scrofulosum : 
diagi 

pathology i 
sympi 
treatment ol 
Lichen simplex, 174. 

syphiliticus, 512. 

tropicus, 242. 

urticatus, 160. 
Light, in dias 
Linese albicantes, 443. 
Linear atrophy, 442. 
Liomyoma cut 

Liquor carbonis detergens, 199. 
Liquor picis alkalinus, l'o4. 
Lividities of the skin. 147. 
Lobular angioma, 564. 
Local idiopathic papilloma, 392. 
Local treatment, 102. 
Locality of disease in symptomatol- 
ogy. 67. 
Lombardian leprosy, 505. 
Lotions in treatment, 105. 
Louse, body, 656. 

clothes* 656. 



Louse, crab, 657. 

head, 654. 
Lousiness, 653. 
Lupus erythematodes, 470. 
Lupus erythematosus, 470. 

diagnosis of, 472. 

etiology of, 471. 

pathology of 471. 

prognosis of, 475. 

symptoms of, 470. 

treatment of, 473. 
Lupus sebaceus, 470. 
superficialis, 470. 
vorax, 475. 
Lupus vulgaris. 475. 

diagnosis of, 477. 

etiology of, 177. 

exedens, 475, 476. 

exfoliativus, 470. 

exulcerans, 470. 

hypertrophicus, 476 

pathology of, 177. 

prognosis of, 485. 

symptoms of, 175. 

treatment of, 481. 

tuberculosus, 175. 

verrucosus, 470. 
Lymph-scrotum, 417. 
Lymphadenie cutanee, 562. 
Lymphadenoma 
Lymphangioma cutis, 509. 

tuberosum multiplex, 509. 
Lymphatics of the skin, 31. 



M. 



Maculae, 5 L 

Maculae et striae atrophica?, 422. 

Macular syphilide, 509. 

syphiloderm, 
Macules, 54. 
Madura foot, 490. 

la rosa, 505 
Mai perforant du pied, 491. 
Mai rosso, 505. 
Maladie pediculaire, 
Malignant pustule, I 

papillary dermatitis, 221. 
Mai is pediculi, 653. 
Medicine, influence of, in etiology, 74. 
Medicinal eruptions, 346. 
Melanoderma, 370. 
Melano-sarcoina. 559. 
Melasma, 370. 
Melasma lenticulare, 369. 
Mentagra, 288. 
Mercurial ointment, dermatitis from, 

344. 
Mercury, absorption of, 279. 



INDEX. 



677 



Mercury, dermatitis from, 354. 

in treatment, 101. 
Method of treatment, 96. 
Microsporon furfur, 631. 
Midge, 665. 
Milky sweat, 145. 
Miliaria, 242. 

alba, 242, 243. 
diagnosis of, 245. 
etiology of, 244. 
papulosa, 242. 
pathology of, 244. 
prognosis of, 247. 
rubra, 242, 243. 
symptoms of, 242. 
treatment of, 246. 
vesiculosa, 243. 
Miliaria crystallina (Hebra), 145. 
Miliary fever (note), 242. 

papular syphiloderm, 512. 
pustular syphiloderm, 522. 
Milium, 131. 

diagnosis of, 132. 
etiology of, 132. 
pathology of, 132. 
symptoms of, 131. 
treatment of, 133. 
Mineral spring waters, in treatment, 

102. 
Mite, harvest, 648. 

irritating, 648. 
mower's (note), 648. 
Moist papule, 514. 

wart (note), 389. 
Mole, pigmentary, 396. 
Molluscum cholesterique, 464. 
Molluscum contagiosum, 377. 
Molluscum epitheliale, 377. 

diagnosis of, 381. 
etiology of, 378. 
pathology of, 379. 
prognosis of, 381. 
symptoms of, 377. 
treatment of, 381. 
Molluscum fibrosum, 461. 

diagnosis of, 464. 
etiology of, 462. 
pathology of, 463. 
prognosis of, 464. 
symptoms of, 461. 
treatment of, 464. 
Molluscum pendulum, 461. 
Molluscum sebaceum, 377. 
sessile, 377. 
simplex, 461. 
Morbus elephas, 415. 

maculosus Werlhoffii, 363. 
pedicularis, 653. 
Morphia, dermatitis from, 354. 
Morphcea, 403 



Morphcea, diagnosis of, 411. 

etiology of, 410. 

pathology of, 411. 

prognosis of, 413. 

symptoms of, 408. 

treatment of, 412. 
Morphcea of leprosy (note), 408. 
Morpio, 657. 
Mosquito, 664. 
Mower's mite (note), 648. 
Mucous layer of epidermis, 23. 

papule, 514. 

patch, 514. 
Multiple fungoid papillomatous tu- 
mors of the skin, 562. 
Murrain, 339. 
Muscles of the skin, 37. 
Mycetoma, 490. 
Mycosis fungoide, 562. 
Mycosis microsporina, 629. 
Myoma cutis, 573. 
Myoma telangiectodes, 573. 



X. 



Naavus fiammeus, 563. 

lipomatodes, 376. 

pigmentaire, 376. 

pigmentosus, 376. 

pilosus, 376, 421. 

sanguineus, 563. 

simplex, 563. 

spilus, 376. 

tuberosus, 563. 

vascularis, 563. 
Nsevus papillaris, 392. 
Nasvus unius lateris, 392. 
Nsevus vasculosus, 563. 

pathology of, 564. 

symptoms of, 563. 

treatment of, 564. 

Nasvus verrucosus, 376, 424. 

Nail, atrophy of, 457. 

hypertrophy of, 427. 

ingrowing, 429. 
Nails, 51. 
Narben, 64. 
Nature of the disease, in treatment, 

95. 
Neoplasm, inflammatory fungoid, 

560. 
Neoplasmata, 113, 458. 
Nerve nasvus, 392. 
Nervenschmerz der haut, 577. 
Nerves of the skin, 33. 

medullated, 33. 

non-medullated, 36. 

vaso-motor, 36. 
Nesselausschlag, 158. 



INDEX. 



Nettle rash, 158. 
Neuralgia of the skin, 577. 
Neuroma, 571.' 

multiplex (note), 571. 

of the skin, painful, 571. 
Neuropathic papilloma, 392. 
Neuroses, 114, 576. 
Neurotic excoriations, 366. 
New growths, 84, 113, 458. 
Nits, 654. 

Nodose condition of the hair, 456. 
Noli me tangere, 475. 
Non-parasitic sycosis, 288. 
Norwegian scabies (note), 640. 



Objective symptoms, 53. 
Occupation, influence of, in etiology, 
75. 

in diagnosis, 90. 
Odor hi rein us, 140. 

of the human body (note), 140. 

urinosus, 140. 
Odorous sweat, 140. 
OEstrus, 651. 
Oils, in treatment, 105. 
Oily seborrhoea. 1 17. 
Ointment, diachylon, 201. 

rumex (note*), 286. 

Wilkinson's, 318. 
Ointments, in treatment, 105. 
Oleate of zinc (note), 199. 
Onychauxis. 427. 
Onychia, 428. 

' syphilitic, 428. 
Onycho-grvphosis. 427. 
Onycho-mycosis 
Opium, dermatitis from, 354. 
Osmidrosis, 140. 



Pachydermatocele, 420. 
Pachydermia, 415. 
Pacinian corpuscles, 34. 
Painful neuroma of the skin, 571. 

tubercle, subcutaneous 
Palmar syphiloderm, 515. 
Pannicufus adiposus, 29. 
Papillae, 27. 

Papillary layer of corium, 27. 
Papilloma, 391. 
Papilloma neuroticum, 392. 
Papula?, 55. 
Papular acne, 270. 

eczema. 174. 

miliaria, 242. 



Papular syphilide, 511. 

syphiloderm, 511. 
large, 512. 
miliary, 512. 
small, "512. 

urticaria, 160. 
Papule, moist, 514. 

mucous, 514. 
Papules, 55. 

hypertrophic, 514. 

squamous, 515. 

vegetating, 514. 
Papulo-squamous syphiloderm, 515. 
Parasite, 114, 593." 
Parasitare bartfinne, 623. 
Parasites, 84, 114, 593 
Parasitic mentagra, 023. 

sycosis, 623. 
Parasiticides, in treatment, 107. 
Parchment skin, 439. 
Paronychia, 428. 
Pars papillaris, 27. 

reticularis, 28. 
Patch of disease, 65. 

mucous, 514. 
Pathology, 78. 

anaemia, 80. 

atrophy, 83. 

hemorrhage, 82. 

hyperemia, 7'.». 

hypertrophy, 83. 

inflammation, 80. 

new growtli-. B 1. 

parasit 
Pearly tubercles, 131. 
Pedicularia, 6 
Pediculosis, 653. 
Pediculosis capitis, 653, 659, 661. 

corpori-, > 

diagnosis oi 

etiology of 

prognosis of, 662. 

pubis, 657, 660, 662. 

symptoms of 

treatment of. 661. 
Pediculus capitis, 654. 

corporis, 656. 

pubis, 657. 

vestimenti, 056. 
Peliosis rheumatica, 362. 
Pellagra, 505. 
Pemphigoid eruption, 254. 
Pemphigus, 249. 
acutus, 250. 
cachecticus, 251. 
chronicus, 250. 
diagnosis of, 253. 
etiology of, 252. 
feigned (note), 255. 
foliaceus, 251. 



679 



Pemphigus gahgrsenosus, 251. 

malignus, 251. 

pathology of, 253. 

prognosis of, 251. 

pruriginosus, 250. 

symptoms of, 249. 

syphiliticus, 258. 

treatment of, 255. 

vulgaris, 249. 
Pemphigus prurigineux (note), 230. 

syphiliticus, 253, 528. 
Perforating ulcer of the foot, 491. 
Perspiration, insensible, 19. 

sensible, 19. 
Petechias, 359. 
Phosphorescent sweat, 144. 
Phosphoric acid, dermatitis from, 

355. 
Phosphoridrosis, 144. 
Phosphorus, in treatment, 101. 
Phtheiriasis, 653. 
Phthiriase, 653. 
Phthiriasis, 653. 
Phthirius inguinalis, 657. 

pubis, 657. 
Phymata, 60. 

Physiology of the skin, 17. 
Pian, 503. 

Piebald skin, acquired, 431. 
Piedra, 456. 
Pigeon lice, 663. 
Pigment of the skin, 37. 
Pigmentary mole, 376. 

naevi, 376. 
Pigmentmal, 376. 
Pirates biguttatus, 664. 
Pityriasis, 115. 

Pityriasis maculata et circinata, 326. 
Pityriasis pilaris, 399. 
Pityriasis rosea, 326. 
Pityriasis rubra, 323. 

diagnosis of, 325. 
pathology of, 325. 
symptoms of, 323. 
treatment of, 326. 
Pityriasis simplex, 119. 
Pityriasis versicolor, 629. 
Plantar syphiloderm, 515. 
Plaque muqueuse, 514. 
Plica, 424. 

polonica, 424. 
Podelcoma, 490. 
Pointed condyloma (note), 389. 

wart (note), 389. 
Poison dogwood, dermatitis from, 
341. 
ivy, dermatitis from, 341. 
sumach, dermatitis from, 341. 
vine, dermatitis from, 341. 
eczema from, 182. 



Poisoned wounds, 337. 
Polyidrosis, 134. 
Polytrichia, 422. 
Pomphi, 59. 
Pompholyx, 247. 
Porcupine disease, 394. 
Pores, 17. 
Porrigo decalvans, 448. 

favosa, 593. 

furfurans, 612. 
Port wine mark, 563. 
Post-mortem tubercle, 338. 
Poultices, in treatment, 104. 
Predisposition, influence of, in eti- 
ology, 72. 
Pregnancy, influence of, in etiology, 

74. 
Present general condition, in treat- 
ment, 95. 
Previous history, in treatment, 95. 
Prickle cells, 24. 
Prickly heat, 242. 
Primary lesions, 54. 
Production cornee, 385. 
Prognosis, 109. 
Progressive facial atrophy (note) 

413. 
Progressive facial hemiatrophy (note), 

413. 
Prurigo, 262. 

diagnosis of, 265. 

etiology of,' 263. 

pathology of, 264. 

prognosis of, 267. 

symptoms of, 262. 

treatment of, 266. 
Pruritus, 579. 

ani, 581. 

diagnosis of, 582. 

etiology of, 581. 

localis, 580. 

pathology of, 582. 

prognosis of, 588. > 

scroti, 580. 

senilis, 580. 

symptoms of, 579. 

treatment of, 583. 

universalis, 580. 

vulva?, 580. 
Pruritus hiemalis, 588. 
Psora, 304. 
Psoriasis, 304. 

circinata, 306. 

diagnosis of, 310. 

from eczema, 310. 

lupus erythematosus, 

312. 
seborrhcea, 312. 
syphilis, 311. 
tinea circinata, 312. 



680 



ISDEX. 



Psoriasis, diffusa. 306. 
etiology of, 307. 
guttata, 305. 
gyrata, 306. 
nummularis, 306. 
pathology of, 308. 
prognosis of, 323. 
punctata, 305. 
symptoms of, 304. 
treatment of, constitutional, 313. 
_ local, 317. 
Psoriasis of the mouth and tongue 
(note), 307. 
syphilitica, 515. 
Pterygium of the nail, 427. 
Pulex irritans, 664. 
penetrans, 649. 
Purpura, 300. 

hemorrhagica, 363. 
pathology of 
nrognosis oi 
rneumatica, 362. 
simplex. 360. 
symptoms >>\\ 360. 
treatment of, 364. 
Purpura urticans MO, 301. 

nrticata, 160. 
Pustel 

Pustula maligna, 339. 
Pustulse, 58. 
Pustular acne, 270. 
eczema, 178. 

eezema-form Byphiloderm, 524. 
Byphilide, 521. 
Pustular syphiloderm, 621 s 

large acuminated, 528. 
large Bat, 524. 
miliary, 522. 
small acuminated, 522. 
Email Hat, 524. 
Pustules. 58. 

Pustulo-crustaceous lesions, 522. 
Pyrogallic acid, ointment of, 321. 



Q. 

Quaddeln, 59. 

Quinine, dermatitis from, 355. 

Quinine, in treatment, 98. 



R. 



Recurrent acute eczema. 328. 
Recurrent exfoliative dermatitis, 328. 
Recurrent exfoliative ervthema, 328. 
Respiration by the skin, 19. 
Rete Malpighii, 23. 
mucosum, 23. 



Reticular layer of corium, 28. 
Rhagades, 63. 

Rheumatism of the skin, 577. 
Rhinochoprion penetrans, 649. 
Rhinophyma, 282. 
Rhinoscleroma, 408. 

diagnosis of, 409. 

etiology of, 468. 

pathology of, 469. 

prognosis of, 470. 

symptoms of, 468. 

treatment of, 470. 
Rhus toxicodendron, dermatitis from. 
341. 

venenata, dermatitis from, 341. 
Ringworm, 602. 

crusted. 598. 

honey-comb, 598. 

of the body, 602. 

of the scalp. 612. 

Tokelau, 612. 
Risipola Lombarda, 505. 
Rodent ulcer, 549. 
Rosacea, 568. 
Roseola, 149. 

syphilitica, 509. 
Rougel i iint,.,, cis. 
Rumex ointment (note), 286. 
Rupia, 525, 528. 



s. 



Salicylic acid, dermatitis from, 356. 

Sand tl.a. 649. 

Sandy sweat, 1 18. 

Santonine, dermatitis from, 356. 

Sapo n iridis, 205. 

Sarcoma, 559. 

Sarcoptes scabiei, ''.12. 

hominis, »; 12. 
Satyriasis, 492. 
Scabies, 637. 

diagnosis of, 644 
etiology of, 637. 
Norv» ., 040. 

pathology - 
prognn-i- of 
Bymptoms of, 637. 
treatment of, 645. 
Scales, 01. 
Scars, 64. 

Scherende flechte, 612. 
Schmeerfluss, 115. 
Schuppen, 01. 
Schuppenflechte, 304. 
Sclerem der neugeborenen, 414. 
Sclerema, 400. 
Sclerema neonatorum. 414. 

diagnosis of, 415. 



681 



Sclerema neonatorum, etiology of, 
414. 
pathology of, 414. 
symptoms of, 414. 
treatment of, 415. 
Sclerema of the newborn, 414. 
Sclereme des adultes, 400. 
Scleriasis, 400. 
Scleroderma, 400. 

diagnosis of, 406. 

etiology of, 403. 

pathology of, 404. 

prognosis of, 407. 

symptoms of, 400. 

treatment of, 407. 
Scleroderma neonatorum, 414. 
Sclerodermic, 400. 
Scleroma adultorum, 400. 
Sclerostenosis, 400. 
Scratching, influence of, in etiology, 

76. 
Scrofula, 485. • 

Scrofulide boutonneuse benigne (Ba- 
zin), 262. 

erythemateuse, 470 

tuberculeuse, 475. 
Scrofuloderm, ulcerative, 562. 
Scrofuloderma, 485. 

diagnosis of, 488. 

etiology of, 488. 

symptoms of, 485. 

treatment of, 488. 
Scrofulosis, 485. 
Scurvy, land, 363. 

Seasons, influence of, in etiology, 71. 
Sebaceous cyst, 133. 

diagnosis of, 134. 
pathology of, 134. 
symptoms of, 133. 
treatment of, 134. 
Sebaceous glands, 42. 

matter, 43. 

tumor, 133. 
Sebiparous glands, 42. 
Seborrhagia, 115. 
Seborrhcea, 115. 

capitis, 117. 

corporis, 120. 

diagnosis of, 122. 

etiology of, 121. 

faciei, 119. 

genitalium, 120. 

nasi, 119. 

oleosa, 117. 

pathology of, 122. 

prognosis of, 127. 

sicca, 117. 

symptoms of, 115. 

treatment of, 124. 
Seborrhcea con^estiva, 470. 



Sebum, 43. 

Secondary lesions, 61. 
Secretion, disorders of, 115. 
Senile alopecia, 445. 

atrophy, 443. 

calvities, 445. 
Sex, in diagnosis, 88. 

influence of, in etiology, 71. 
Shingles, 231. 
Simonea folliculorum, 651. 
Simulium, 665. 
Skin, anatomy of, 17. 

appendages, 20. 

bloodvessels, 31. 

corium, 26. 

epidermis, 20. 

granular layer, 22. 

hair-follicle, 47. 

hairs. 44. 

horny layer, 21. 

lanugo, 44. 

lymphatics, 31. 

medullated nerves, 33. 

mucous layer, 23. 

muscles, 37. 

nails, 51. 

nerves, 33. 

non-medullated nerves, 36. 

Pacinian corpuscles, 34. 

papillary layer, 27. 

pigment, 37. 

reticular layer, 28. 

sebaceous glands, 42. 

sebaceous matter, 43. 

stratum lucidum, 22. 

subcutaneous connective tissue, 
29. 

sweat glands, 38. 

tactile corpuscles, 33. 
Smegma, 116. 
Soaps, influence of, in etiology, 75. 

in treatment, 103. 
Sommersprosse, 368. 
Spargosis, 415. 
Special diseases, 115. 
Spedalskhed, 492. 
Spiritus saponatus kalinus, 322. 
Spitze condylom (note), 389. 
Spots, 54. 
Squamse, 61. 
Squames, 61. 
Squamous papule, 56. 

papules, 615. 

syphilide, 515. 

syphiloderm, 515. 
Stage of disease, in diagnosis, 90. 
Stain, claret, 563. 
Stearrhcea, 115. 
Steatoma, 133. 
Steatorrhea, 115. 



682 



IXDEX. 



Steatozoon folliculorum, 651. 
Stigmata, bleeding. 366. 
Stinking sweat, 140. 
Stone-pock, 268. 

Stramonium, dermatitis from. 356. 
Stratum corneum of epidermis, 21. 

granulosum of epidermis, 22. 

lucidum of epidermis, 22. 

Malpighii, 23. 

mueosum of epidermis, 23. 

of Oehl, 22. 
Striae et maculae atrophica?, 442. 

idiopathic, 442. 
symptomatic, 443. 
Strophulus albidus, 131. 
Strophulus prurigineux (Hardy), 262, 

(note) iv, i. 
Struma, 485. 

Strychnia, dermatitis from, 357. 
Subcutaneous connective tissue, 29. 

painful tubercle. 
Subjective Bymptoms, 68. 
Sudamen, 14"i. 

etiology of, 1 15. 

pathology of, 1 16. 

symptoms of, 145. 
Sudamina | lb-bra . 212. 
Sudatoria, 184. 

Sudden graying of the hair, 435. 
Sudor anglicus | note . 242. 

cruenta, 866. 
Sudoriparous -land-. 38. 
Sudor urinosus, 1 13. 

sanguineosa, 866. 

Sweat. 40. 

bloody, :ril. 
colored, 142. 
phosphorescent, 144. 
Sweat glands, 38. 
Sweating, excessive, 134. 
Sweating Bicknese | note), 242. 
Swelling and bursting of the hair, 

4 ■">•">. 
Sycosis, 288. 

contagiosa, 023. . 
non-parasitaire, 288. 
Sycosis non-parasitii 

diagnosis of. 200. 
etiology of. 289. 
pathology of, 289. 
prognosis of, : 
symptoms of, 288. 
treatment of, 201. 
Sycosis parasitaire, 623. 
parasitaria, 623. 
parasitica, 623. 
Symmetry of disease, in symptoma- 
tology,' 67. 
Symptomatic diseases, 58. 
Symptomatic hemorrhage, 359. 



Symptomatic papilloma, 392. 
Symptomatology, 53. 

blebs, 57. 

color in, 68. 

configuration in, 66. 

crusts, 61. 

distribution in. 66. 

excoriations, 62. 

fissures. 68. 

general symptoms in, 65. 

locality in. 67. 

macules, 54. 

objective symptoms, 53. 

papules, 56, 

primary lesions, 54. 

pustules, 58. 

scales, 'il. 

scars. 64. 

secondary lesions, 61. 

tive symptoms, 68. 

symmetry in. 67. 

tuber.-].-. 60. 

tumor-. 60. 

ulcers. 6 I 

vesicles, 56. 

wheals, 59. 
Symptoms, general, 65. 

objective, 53. 

subjective 
Syphilid.-, arn. -form, 523. 

bullous, 528. 

cornec, 516. 

ecthyma-!'.. rni, .",24. 

erythematous, 509. 

gummatous, oL'7. 

herpetiform (note), 522. 

impetigo-form, 524. 

large acuminated pustula 

large flat pustular, 524. 

large papular, -",12. 

lenticular papular, 512. 

macular, 509. 

miliary papular, 512. 

miliary pustular, 522. 

palmar, 516. 

papular. 51 1. 

papulo-squamous, 515. 

pigmentary, 520. 

plantar. 'A',. 

pustular, 521. 

pustular eczema-form, 524. 

serpiginous tubercular, "-i";. 

small acuminated pustular, 522 

small flat pustular, ."324. 

small papular. -j12. 

squamous, 515. 

tubercular. 525. 

varicella-form. 519. 

variola-form. 523. 

vegetating, 514. 



683 



Syphilide, vesicular, 519. 
Syphilides, 506. 
Syphilis, congenital, 529. 
hereditary, 529. 
infantile, 529. 
of the skin, 506. 
Syphilis cutanea, 506. 

bullosa, 528. 

erythematosa, 509. 

gummatosa, 527. 

maculosa, 509. 

papillomatosa, 526. 

papulosa, 511. 

pustulosa, 521. 

squamosa, 515. 

tuberculosa, 525. 

vegetans, 514. 

vesiculosa, 519. 
Syphilitic acne, 523. 
alopecia, 446. 
coryza, 530. 
ecthyma, 524. 
impetigo, 524. 
lichen, 512. 
onychia, 428. 
pemphigus, 528. 
psoriasis, 515. 
roseola, 509. 
rupia, 525, 528. 
Syphiloderm, acne-form, 523. 
bullous, 528. 
ecthyma-form, 524. 
eczema-form, 524. 
erythematous, 509. 
gummatous, 9fi7. 
herpetiform (note), 522. 
impetigo-form, 521. 
large acuminated pustular, 523. 
large flat pustular, 524. 
large papular, 512. 
lenticular papular, 512 
macular, 509. 
miliary papular, 512. 
miliary pustular, 522. 
palmar, 515. 
papular, 511. 
papulo-squamous, 515. 
pigmentary, 520. 
plantar, 515. 
pustular, 521. 
pustular eczema-form, 524. 
serpiginous tubercular, 526. 
small acuminated pustular, 522. 
small flat pustular, 524. 
small papular, 512. 
squamous, 515. 
tubercular, 525. 
varicella-form, 519. 
variola-form, 523. 
vegetating, 514. 



Syphiloderm, vesicular, 519. 
Syphiloderma, 506. 

absence ^of itching in, 508. 

bullosum, 528. 

color of, 508. 

concomitant symptoms in, 507. 

configuration of the lesions in, 
508. 

constitutional treatment of, 534. 

course of, 508. 

erythematosum, 509. 

general symptoms in, 506. 

gummatosum, 527. 

hsereditarium infantile, 529. 

local treatment of, 545. 

multiformity of the lesions in, 
507. 

papulosum, 511. 

pathology of, 529. 

pigmentosum, 520. 

pustulosum, 521. 

seat of, 507. 

squamosum, 515. 

subjective symptoms, 508. 

treatment of, 534. 

tuberculosum, 525. 

vesiculosum, 519. 
Syphiloma, 527. 



T. 



Tache de feu, 563. 
Taches, 54. 

Tactile corpuscles, 33. 
Tar acne, 271. 
Tar, in treatment, 101. 
Tattooing, 370. 
Teigne faveuse, 593. 
tondante, 612. 
tonsurante, 612. - ■ 
Telangiectasis, 568. 
Temperament, in diagnosis, 89. 
Temperature, in diagnosis, 86. 
Tetter, 169. 
Tick, 665. 
Tinctura saponis viridis cum pice, 

319. 
Tinea amiantacea, 115. 

asbestina, 115. 
Tinea circinata, 602. 

cruris, 603. 

diagnosis of, 608. 

etiology of, 605. 

pathology of, 606. 

prognosis of, 611. 

symptoms of, 602. 

treatment of, 609. 
Tinea decalvans, 448. 
Tinea favosa, 593. 



684 



IXDEX. 



Tinea favosa, diagnosis of, 599. 

etiology of, 596. 

pathology of, 5$6. 

prognosis of, 601. 

symptoms of, 593. 

treatment of, 599. 
Tinea furfuracea, 115. 
Tinea imbrieata. 611. 
Tinea kerion, 622. 
Tinea sycosis ill':;. 

diagnosis of, 027. 

etiology of. 024. 

pathology of, 025. 

prognosis of, 629. 

symptoms of, 623. 

treatment of, 628. 
Tinea tondens, 612. 
Tinea tonsurans 612. 

diagnosis of, 617. 

etiology of, 615. 

pathology of, 615. 

prognosis of, 021. 

symptoms of, 012. 

treatment of. 619. 
Tinea trichophytina, G01. 
Tinea unguium, 605. 
Tinea versicolor, 629. 

diagnosis of, 024. 

etiology of, 031. 

pathology of, 682. 

prognosis of, 687. 

symptoms •.)'. 629. 

treatment of, ''.:;.-,. 

Tissue, adi] 

subcutaneous connective, 29. 
Tokelau ringworm, 012. 
Treatment. 94. 

cause of the disease in, 96. 
constitutional, 97. 

aperients in, 102. 

arsenic ii 

cod- liver oil in, 97. 

diuretics in, 102. 

food in. 97. 

hygiene in, 97. 

iodide of potassium in, 101. 

iron in, 98. 

mercury in, 101. 

mineral spring waters in, 102. 

phosphorus in, 101. 

quinine in, 98. 

tar, carbolic acid in, 101. 
local, 102. 

bandages in. 104. 

baths in, 102. 

caustics in, 106. 

dusting powders in, 104. 

electricity in, 108. 

lotions in, 105. 

oils in, 105. 



Treatment, local, ointments in, 105. 
parasiticides in, 107. 
poultices in, 104. 
soaps in, 103. 

method of, 90. 

nature of the disease in, 95. 

present general condition in, 95. 

previous history in, 95. 
Trichauxis, 422. 
Trichiasis, 424. 
Trichonosis cana, 435. 

discolor, 435. 

furfuracea, 012. 
Trichorexis nodosa, 455. 
Trichopbytie circinee, 602i 

sycosique, 623. 
Trichophyton, 002, 015, 024. 

tonsurans, 0].",. 
Tricoptilosis, 455. 

Trophoneurosis facialis (note), 413. 
True skin, 20. 
Tubercle, subcutaneous painful, 573. 

anatomical, 338. 

dissection, 338. 

post-mortem, 338. 
Tubercles, 60. 
Tubercula, 60. 

miliaria, 131. 
ea, 131. 
Tubercular leprosy, 493. 

syphilide, 525. 
Tubercular syphiloderm, 525. 

serpiginous, 520. 
Tubercules, 00. 
Tuberculosis of the skin, 489. 
Tumeurs, 60. 

Tumeurs folliculeuses, 377. 
Tumor, enevsted, 133. 

follicular, 133. 

gummy, 527. 

sebaceous, 188. 
Tumores, 

sebipari, :;77. 
Tumors, 60. 

multiple fungoid papillomatous, 
562. 

multiple of the skin accompanied 
by intense itching, '•*■■;. 
Turpentine, dermatitis from 
Two-spotted corsair, 664. 
Tvloma, 382. 
Tylosis, 382. 



U. 

Ulcer, perforating, of foot, 491 

Ulcer, rodent, 54!j. 

Ulcera, 64. 

Ulcerative scrofuloderm, 562 



INDEX. 



685 



Ulceres, 64. 
Ulcers, 64. 

Uncleanliness, influence of, in etiol- 
ogy, 76. 
Unilateral atrophy of the face, 413. 
Uridrosis, 143. 
Urinidrosis, 143. 
Urinous sweat, 143. 
Urticae, 59. 
Urticaire, 158. 
Urticaria, 158. 

acute, 161. 

bullosa, 160. 

chronic, 161. 

diagnosis of, 163. 

etiology of, 162. 

hemorrhagica, 160. 

papulosa, 160. 

pathology of, 163. 

prognosis of, 167. 

symptoms of, 158. 

treatment of, 164. 

tuberosa, 161. 
Urticaria pigmentosa, 167. 



Vaccination, influence of, in etiology, 

74. 
Varicella-form syphifoderm, 519. 
Variola-form syphiloderm, 523. 
Varus, 268. 
Vegetating papules, 514. 

syphiloderm, 514. 
Vegetation dermique (note), 389. 
Venereal wart (note), 389. 
Vernix caseosa, 116. 
Verruca, 387. 

acuminata, 389. 

digitata, 388. 

elevata (note), 389. 

etiology of, 390. 

filiformis, 388. 

minimse, 388. 

pathology of, 390. • 

plana, 388. 

prognosis of, 391. 

senilis, 388. 

symptoms of, 887. 

treatment of, 390. 

vegetantes, 389. 

vulgaris, 388. 
Verruca necrogenica, 338. 
Verrue, 387. 
Verrucous nsevus, 392. 
Verrugas, endemic, 503. 
Vesicles, 56. 
Vesiculse, 56. 
Vesicules, 56. 



Vesicular eczema, 172. 

miliaria, 243. 

syphilide, 519. 

syphiloderm, 519. 
Vibiees, 359. 
Vitiligo, 432. 

diagnosis' of, 433. 

etiology of, 433.. 

pathology of, 433. > 

prognosis of, 434. 

symptoms of, 432. 

treatment of, 434. 
Vitiligoidea, 464. 
Vleminckx's solution, 322. 



W. 

Wart, 387. 

common, 387. 

fig (note), 389. 

moist (note), 389. 

pointed (note), 389. 

venereal (note), 389. 
Warze, 387. 
"Wen, 133. 

Werlhoffii, morbus maculosus, 363. 
Wheals, 59. 
Whelk, 268. 

Whiteness of the hair, 435. 
Wilkinson's ointment, 318. 
W x ood-tick, 665. 
Wounds, dissection, 338. 

poisoned, 337. 



Xanthelasma, 464. 
Xantbelasmoidea, 168. 
Xanthoma, 464. 

etiology of, 466. 

multiplex, 465. 

pathology of, 466. 

planum, 464. 

symptoms of, 464. 

treatment of, 467. 

tuberosum, 464. 
Xeroderma, 393, 439. 

ichthvoides, 393. 

of Hebra, 439. 



Yaws, 503. 



Zellgewebsverhartung der neugebo- 

•renen, 414. 
Zona, 231. 
Zoster, 231. 



"THE MOST VALUABLE WORK OF ITS KIND EVER PUBLISHED. 



ATLAS OF SKIN DISEASES. 

By LOUIS A. DUHRING, M.D., 

Professor of Skin Diseases in the Hospital of the University of Pennsyl- 
vania; Dermatologist to the Philadelphia Hospital; Consulting 
Physician to the Dispensary for Skin Diseases, Philadel- 
phia ; Author of " Diseases of the Skin," etc. 



CONTENTS 

ANOMALia; SECRETIONIS HYPERTROPHIC 

SEBORRHCGA ICHTHYOSIS (simplex) 



EXSUDATIONES 

ERYTHEMA MULTIFORME (papulosum) 

ERYTHEMA NODOSUM 

ECZEMA (erythematosum) 

ECZEMA (papulosum) 

ECZEMA (vesiculosum) 

ECZEMA (pustulosum) 

ECZEMA (squamosum) 

ECZEMA (rubrum) 

ECZEMA (rubrum) 

ECZEMA (rubrum) 

HERPES ZOSTER 

PEMPHIGUS 

ACNE ROSACEA 

SYCOSIS NON-PARASITICA 

IMPETIGO CONTAGIOSA 

ECTHYMA 

PSORIASIS 

PSORIASIS 

HEMORRHAGIC 
PURPURA (simplex) 



ATROPHIC 

VITILIGO 
ALOPECIA AREATA 

NEOPLASMATA 

LUPUS ERYTHEMATOSUS 
LUPUS VULGARIS 
SYPHILODERMA (erythematosum) 
SYPHILODERMA (papulosum) 
SYPHILODERMA (papulosum et pustulosum) 
SYPHILODERMA (pustulosum) 
SYPHILODERMA (pustulosum) 
SYPHILODERMA (tuberculosum) 

PARASITE 
TINEA FAVOSA 

TINEA TRICHOPHYTINA (circinata et ton- 
surans) 
TINEA SYCOSIS 
TINEA VERSICOLOR 
SCABIES 



The Atlas consists of a series of original, nearly life-size chromo-litho- 
graphic illustrations, painted from life, representing the most important 
diseases met with in the United States. For the portraits of the cases, the 
Publishers are pleased to state that they are indebted to the skill of the well- 
known artist, Mr. Hermann Faber. The drawings are reproduced in the 
very highest style of the chromo-lithographic art, under theimmediate super- 
vision of Mr. F. Moras, whose name in association with chromo-lithography 
is a sufficient guarantee for artistic productions of the highest order. 



IN ONE VOLUME. LARGE 4TO. HALF MOROCCO. 

PRICE, $25.00. 



OPINIONS OF THE PRESS 

CONCERNING 

The Atlas of Skin Diseases. 



"The high expectations raised by the earlier parts of this Atlas continue to be 
abundantly satisfied, and there is certainly no falling off either in the care with which 
the subjects have been selected, or in the beautiful execution of the chromo-lithography. 
Dr. Duhring's efforts in this Atlas have been crowned with great success, and he is 
giving us portrayals of skin diseases by far the most truthful that have yet appeared." 
— Loudon Lancet. 

"The most magnificent colored illustrations ever published in this country." — New 
Orleans Medical and Surgical Journal. 

"The ebromo-lithographs are executed with wondrous fidelity." — Medical and 
Surgical Reporter. 

" We congratulate Prof. Duhring on the accomplishment of his arduous labor in 
connection with this truly monumental production. It is a work which will last when 
systems and treatises are obsolete and forgotten." — Philadelphia Medical Times. 

" Nothing superior to these plates in the way of a pathological atlas has ever been 
issued in this country, and those who require a series of colored plates of skin affections 
need expect nothing better. The drawings are sufficiently large to enable the smallest 
details to be shown with distinctness and fidelity.'' — New Remedies. 

" The plates are of great artistic excellence, and arc faithful copies of diseased 
appearances." — London Practitiont r. 

"A most beautiful and perfect work." — American Practitioner. 

"The artistic reproduction of the portraits has been most ably accomplished. We 
bespeak genuine success for this beautiful work." — Vierteljahresechrift fUr Derma- 
tologie und Syphilis, Vienna. 

" We have nothing but praise to give in noticing it; the plates are excellent in 

every way. We have Been none to eqnal them as truthful representations of typical 

The text is clear and concise." — Toronto Journal of Medical 

"The finest and most useful work of its kind that we have ever seen." — Chicago 
Journal of Nervous and Mental Dim 

"The plates are model- of artistic worth, guided by intelligent and experienced 
medical judgment ; they are thoroughly true to nature." — Archives nf Dermatology. 

"The illustrations are artistically executed, and display remarkable accuracy both 
in drawing and coloring." — Glasgow Medical Journal. 

" Nothing even approaching the work has ever yet been given to the world, if we, 
perhaps, except the work of Elliuger and Heitzmano in the Vienna atlases." — Boston 
Medical and Surgical Journal. 

" The Atlas is a credit to the author as a dermatologist, to the artists who have 
worked so faithfully upon it, and to the publishers for the excellence of its general 
appearance, and deserves the most liberal support from the profession." — American 

Journal of the .1/' rfti 

" We need only mention the appearance of these accurate and excellent chromo- 
lithographs. Dr. Duhring's authority in the field of dermatology is undisputed. Those 
who have the means to Supply themselves with the series cannot spend the money to 
better advantage." — Cincinnati Clinic. 

" We have seen nothing from the American press equal in beauty and style to this 
work." — Pacific Medical and Surgical Journal. 

" Every American physician ought to feel proud of this splendid work, for, indeed, 
it is not surpassed in excellence by any European book on the subject." — West Virginia. 
Medical Student. 

"The Atlas, in its completed form, is the best and cheapest atlas of skin diseases 
with which we are acquainted, and reflects the utmost credit upon its author and its 
publishers." — Dublin Journal of Medical Science. 



figg"* For sale by all Medical Booksellers, or will be sent, transportation 
free, by 

J. B. LIPPINCOTT & CO., Publishers, Philadelphia. 



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